hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|WY,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Wyoming Medical Center,    2024-10-07,2.0.0,Wyoming Medical Center - East Campus,"6550 E 2ns Street Casper, WY 82601-2926",15341,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,code|4,code|4|type,code|5,code|5|type,modifiers,setting,billing_class,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,standard_charge|min,standard_charge|max,additional_generic_notes,standard_charge|39 North|39 North|negotiated_dollar,standard_charge|39 North|39 North|negotiated_percentage,standard_charge|39 North|39 North|negotiated_algorithm,standard_charge|39 North|39 North|methodology,estimated_amount|39 North|39 North,additional_payer_notes|39 North|39 North,standard_charge|Aetna Banner Employee|Aetna Banner Employee|negotiated_dollar,standard_charge|Aetna Banner Employee|Aetna Banner Employee|negotiated_percentage,standard_charge|Aetna Banner Employee|Aetna Banner Employee|negotiated_algorithm,standard_charge|Aetna Banner Employee|Aetna Banner Employee|methodology,estimated_amount|Aetna Banner Employee|Aetna Banner Employee,additional_payer_notes|Aetna Banner Employee|Aetna Banner Employee,standard_charge|BCBS|BCBS|negotiated_dollar,standard_charge|BCBS|BCBS|negotiated_percentage,standard_charge|BCBS|BCBS|negotiated_algorithm,standard_charge|BCBS|BCBS|methodology,estimated_amount|BCBS|BCBS,additional_payer_notes|BCBS|BCBS,standard_charge|BCBS|BCBS Blue Select PPO|negotiated_dollar,standard_charge|BCBS|BCBS Blue Select PPO|negotiated_percentage,standard_charge|BCBS|BCBS Blue Select PPO|negotiated_algorithm,standard_charge|BCBS|BCBS Blue Select PPO|methodology,estimated_amount|BCBS|BCBS Blue Select PPO,additional_payer_notes|BCBS|BCBS Blue Select PPO,standard_charge|BCBS|BCBS Federal FEHB|negotiated_dollar,standard_charge|BCBS|BCBS Federal FEHB|negotiated_percentage,standard_charge|BCBS|BCBS Federal FEHB|negotiated_algorithm,standard_charge|BCBS|BCBS Federal FEHB|methodology,estimated_amount|BCBS|BCBS Federal FEHB,additional_payer_notes|BCBS|BCBS Federal FEHB,standard_charge|BCBS|BCBS Medicare Advantage|negotiated_dollar,standard_charge|BCBS|BCBS Medicare Advantage|negotiated_percentage,standard_charge|BCBS|BCBS Medicare Advantage|negotiated_algorithm,standard_charge|BCBS|BCBS Medicare Advantage|methodology,estimated_amount|BCBS|BCBS Medicare Advantage,additional_payer_notes|BCBS|BCBS Medicare Advantage,standard_charge|Cigna|Cigna Commercial|negotiated_dollar,standard_charge|Cigna|Cigna Commercial|negotiated_percentage,standard_charge|Cigna|Cigna Commercial|negotiated_algorithm,standard_charge|Cigna|Cigna Commercial|methodology,estimated_amount|Cigna|Cigna Commercial,additional_payer_notes|Cigna|Cigna Commercial,standard_charge|Cigna|Cigna FEHB|negotiated_dollar,standard_charge|Cigna|Cigna FEHB|negotiated_percentage,standard_charge|Cigna|Cigna FEHB|negotiated_algorithm,standard_charge|Cigna|Cigna FEHB|methodology,estimated_amount|Cigna|Cigna FEHB,additional_payer_notes|Cigna|Cigna FEHB,standard_charge|First Choice of Midwest|First Choice of Midwest|negotiated_dollar,standard_charge|First Choice of Midwest|First Choice of Midwest|negotiated_percentage,standard_charge|First Choice of Midwest|First Choice of Midwest|negotiated_algorithm,standard_charge|First Choice of Midwest|First Choice of Midwest|methodology,estimated_amount|First Choice of Midwest|First Choice of Midwest,additional_payer_notes|First Choice of Midwest|First Choice of Midwest,standard_charge|Coventry First Health|First Health|negotiated_dollar,standard_charge|Coventry First Health|First Health|negotiated_percentage,standard_charge|Coventry First Health|First Health|negotiated_algorithm,standard_charge|Coventry First Health|First Health|methodology,estimated_amount|Coventry First Health|First Health,additional_payer_notes|Coventry First Health|First Health,standard_charge|Health InfoNet First Choice|Health InfoNet First Choice|negotiated_dollar,standard_charge|Health InfoNet First Choice|Health InfoNet First Choice|negotiated_percentage,standard_charge|Health InfoNet First Choice|Health InfoNet First Choice|negotiated_algorithm,standard_charge|Health InfoNet First Choice|Health InfoNet First Choice|methodology,estimated_amount|Health InfoNet First Choice|Health InfoNet First Choice,additional_payer_notes|Health InfoNet First Choice|Health InfoNet First Choice,standard_charge|Humana Medi Advan|Humana Medi Advan|negotiated_dollar,standard_charge|Humana Medi Advan|Humana Medi Advan|negotiated_percentage,standard_charge|Humana Medi Advan|Humana Medi Advan|negotiated_algorithm,standard_charge|Humana Medi Advan|Humana Medi Advan|methodology,estimated_amount|Humana Medi Advan|Humana Medi Advan,additional_payer_notes|Humana Medi Advan|Humana Medi Advan,standard_charge|Medica Commercial|Medica Commercial|negotiated_dollar,standard_charge|Medica Commercial|Medica Commercial|negotiated_percentage,standard_charge|Medica Commercial|Medica Commercial|negotiated_algorithm,standard_charge|Medica Commercial|Medica Commercial|methodology,estimated_amount|Medica Commercial|Medica Commercial,additional_payer_notes|Medica Commercial|Medica Commercial,standard_charge|Medicare|Medicare|negotiated_dollar,standard_charge|Medicare|Medicare|negotiated_percentage,standard_charge|Medicare|Medicare|negotiated_algorithm,standard_charge|Medicare|Medicare|methodology,estimated_amount|Medicare|Medicare,additional_payer_notes|Medicare|Medicare,standard_charge|Mountain Health Co Op|Mountain Health Co Op|negotiated_dollar,standard_charge|Mountain Health Co Op|Mountain Health Co Op|negotiated_percentage,standard_charge|Mountain Health Co Op|Mountain Health Co Op|negotiated_algorithm,standard_charge|Mountain Health Co Op|Mountain Health Co Op|methodology,estimated_amount|Mountain Health Co Op|Mountain Health Co Op,additional_payer_notes|Mountain Health Co Op|Mountain Health Co Op,standard_charge|Multiplan|Multiplan|negotiated_dollar,standard_charge|Multiplan|Multiplan|negotiated_percentage,standard_charge|Multiplan|Multiplan|negotiated_algorithm,standard_charge|Multiplan|Multiplan|methodology,estimated_amount|Multiplan|Multiplan,additional_payer_notes|Multiplan|Multiplan,"standard_charge|Naphcare Wyoming, LLC|Naphcare|negotiated_dollar","standard_charge|Naphcare Wyoming, LLC|Naphcare|negotiated_percentage","standard_charge|Naphcare Wyoming, LLC|Naphcare|negotiated_algorithm","standard_charge|Naphcare Wyoming, LLC|Naphcare|methodology","estimated_amount|Naphcare Wyoming, LLC|Naphcare","additional_payer_notes|Naphcare Wyoming, LLC|Naphcare",standard_charge|Naphcare Federal Inmates|Naphcare Federal Inmates|negotiated_dollar,standard_charge|Naphcare Federal Inmates|Naphcare Federal Inmates|negotiated_percentage,standard_charge|Naphcare Federal Inmates|Naphcare Federal Inmates|negotiated_algorithm,standard_charge|Naphcare Federal Inmates|Naphcare Federal Inmates|methodology,estimated_amount|Naphcare Federal Inmates|Naphcare Federal Inmates,additional_payer_notes|Naphcare Federal Inmates|Naphcare Federal Inmates,standard_charge|TriCare East Humana Military|TriCare East Humana Military|negotiated_dollar,standard_charge|TriCare East Humana Military|TriCare East Humana Military|negotiated_percentage,standard_charge|TriCare East Humana Military|TriCare East Humana Military|negotiated_algorithm,standard_charge|TriCare East Humana Military|TriCare East Humana Military|methodology,estimated_amount|TriCare East Humana Military|TriCare East Humana Military,additional_payer_notes|TriCare East Humana Military|TriCare East Humana Military,standard_charge|TRICARE OVERSEAS|TRICARE OVERSEAS|negotiated_dollar,standard_charge|TRICARE OVERSEAS|TRICARE OVERSEAS|negotiated_percentage,standard_charge|TRICARE OVERSEAS|TRICARE OVERSEAS|negotiated_algorithm,standard_charge|TRICARE OVERSEAS|TRICARE OVERSEAS|methodology,estimated_amount|TRICARE OVERSEAS|TRICARE OVERSEAS,additional_payer_notes|TRICARE OVERSEAS|TRICARE OVERSEAS,standard_charge|Tricare West HealthNet|Tricare West HealthNet FS|negotiated_dollar,standard_charge|Tricare West HealthNet|Tricare West HealthNet FS|negotiated_percentage,standard_charge|Tricare West HealthNet|Tricare West HealthNet FS|negotiated_algorithm,standard_charge|Tricare West HealthNet|Tricare West HealthNet FS|methodology,estimated_amount|Tricare West HealthNet|Tricare West HealthNet FS,additional_payer_notes|Tricare West HealthNet|Tricare West HealthNet FS,standard_charge|TRIWEST|TRIWEST|negotiated_dollar,standard_charge|TRIWEST|TRIWEST|negotiated_percentage,standard_charge|TRIWEST|TRIWEST|negotiated_algorithm,standard_charge|TRIWEST|TRIWEST|methodology,estimated_amount|TRIWEST|TRIWEST,additional_payer_notes|TRIWEST|TRIWEST,standard_charge|United Healthcare|UHC Commercial|negotiated_dollar,standard_charge|United Healthcare|UHC Commercial|negotiated_percentage,standard_charge|United Healthcare|UHC Commercial|negotiated_algorithm,standard_charge|United Healthcare|UHC Commercial|methodology,estimated_amount|United Healthcare|UHC Commercial,additional_payer_notes|United Healthcare|UHC Commercial,standard_charge|United Healthcare|UHC FEHB|negotiated_dollar,standard_charge|United Healthcare|UHC FEHB|negotiated_percentage,standard_charge|United Healthcare|UHC FEHB|negotiated_algorithm,standard_charge|United Healthcare|UHC FEHB|methodology,estimated_amount|United Healthcare|UHC FEHB,additional_payer_notes|United Healthcare|UHC FEHB,standard_charge|UHC Medi Advan|UHC Medi Advan|negotiated_dollar,standard_charge|UHC Medi Advan|UHC Medi Advan|negotiated_percentage,standard_charge|UHC Medi Advan|UHC Medi Advan|negotiated_algorithm,standard_charge|UHC Medi Advan|UHC Medi Advan|methodology,estimated_amount|UHC Medi Advan|UHC Medi Advan,additional_payer_notes|UHC Medi Advan|UHC Medi Advan,standard_charge|Veterans Administration|Veterans Administration|negotiated_dollar,standard_charge|Veterans Administration|Veterans Administration|negotiated_percentage,standard_charge|Veterans Administration|Veterans Administration|negotiated_algorithm,standard_charge|Veterans Administration|Veterans Administration|methodology,estimated_amount|Veterans Administration|Veterans Administration,additional_payer_notes|Veterans Administration|Veterans Administration,standard_charge|Medicaid WY|WY Medicaid|negotiated_dollar,standard_charge|Medicaid WY|WY Medicaid|negotiated_percentage,standard_charge|Medicaid WY|WY Medicaid|negotiated_algorithm,standard_charge|Medicaid WY|WY Medicaid|methodology,estimated_amount|Medicaid WY|WY Medicaid,additional_payer_notes|Medicaid WY|WY Medicaid
ROOM AND BOARD NURSERY LEVEL 3,10272,CDM,173,RC,,,,,,,,inpatient,facility,,,7700,3234,6545,7700,,6545,,,percent of total billed charges,,,,,,,,,7700,,,case rate,,,7700,,,case rate,,,,,,,,,,,,,,,6699,,,percent of total billed charges,,,,,,,,,6930,,,percent of total billed charges,,,7392,,,percent of total billed charges,,,7315,,,percent of total billed charges,,,,,,,,,6930,,,percent of total billed charges,,,,,,,,,7161,,,percent of total billed charges,,,7315,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7700,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,11049,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,11064,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,12369,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,12419,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,12435,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,12450,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,13276,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,19265,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD ICU INTERMEDIATE,19406,CDM,206,RC,,,,,,,,inpatient,facility,,,4400,1848,3740,4400,,3740,,,percent of total billed charges,,,,,,,,,4400,,,case rate,,,4400,,,case rate,,,,,,,,,,,,,,,3828,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,4224,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,3960,,,percent of total billed charges,,,,,,,,,4092,,,percent of total billed charges,,,4180,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4400,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD MEDICAL SURGICAL SEMI PVT,21048,CDM,121,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD MEDICAL SURGICAL SEMI PVT,21063,CDM,121,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD MEDICAL SURGICAL SEMI PVT,22368,CDM,121,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD MEDICAL SURGICAL SEMI PVT,22418,CDM,121,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD MEDICAL SURGICAL SEMI PVT,22434,CDM,121,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD PEDIATRICS SEMI PVT,2360,CDM,123,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD PEDIATRICS SEMI PVT,2436,CDM,123,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ BEBTELOVIMAB W POST MNTR,2600302,CDM,260,RC,M0222,HCPCS,,,,,,inpatient,facility,,,552,231.84,469.2,529.92,,469.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.24,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ BEBTELOVIMAB W POST MNTR,2600302,CDM,260,RC,M0222,HCPCS,,,,,,outpatient,facility,,,552,231.84,149.04,529.92,,469.2,,,percent of total billed charges,,,149.04,,,percent of total billed charges,,,379.78,,,percent of total billed charges,,,371.5,,,percent of total billed charges,,,466.44,,,percent of total billed charges,,,,,,,,,480.24,,,percent of total billed charges,,,480.24,,,percent of total billed charges,,,469.2,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,375.39,,,fee schedule,,,375.39,,,fee schedule,,,367.88,,,fee schedule,,,,,,,,,431.11,,,percent of total billed charges,,,502.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ BEBTELOVIMAB W POST MNTR,2600302,CDM,260,RC,M0222,HCPCS,1505,APC,,,,outpatient,facility,,,552,552,190.39,544.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,382.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,375.39,,,fee schedule,,,,,,,,,,,,,,,544.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",506.78,,,fee schedule,,,,,,,,,,,,,,,,,,,,,375.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,375.39,,,fee schedule,,,375.39,,,fee schedule,,,190.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INF IV HYDRATION 31 60MIN,2601359,CDM,260,RC,96360,CPT,,,,,,inpatient,facility,,,388,162.96,329.8,372.48,,329.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.56,,,percent of total billed charges,,,,,,,,,349.2,,,percent of total billed charges,,,372.48,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.84,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF IV HYDRATION 31 60MIN,2601359,CDM,260,RC,96360,CPT,,,,,,outpatient,facility,,,388,162.96,104.76,372.48,,329.8,,,percent of total billed charges,,,104.76,,,percent of total billed charges,,,266.94,,,percent of total billed charges,,,261.12,,,percent of total billed charges,,,327.86,,,percent of total billed charges,,,,,,,,,337.56,,,percent of total billed charges,,,337.56,,,percent of total billed charges,,,329.8,,,percent of total billed charges,,,372.48,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,349.2,,,percent of total billed charges,,,,,,,,,360.84,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,214.35,,,fee schedule,,,,,,,,,303.03,,,percent of total billed charges,,,353.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF IV HYDRATION 31 60MIN,2601359,CDM,260,RC,96360,CPT,5693,APC,,,,outpatient,facility,,,388,388,112.21,317.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,317.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",295.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,218.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,112.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INF IV HYDRATION ADDL HR,2601367,CDM,260,RC,96361,CPT,,,,,,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF IV HYDRATION ADDL HR,2601367,CDM,260,RC,96361,CPT,,,,,,outpatient,facility,,,103,43.26,27.81,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,,,,,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,48.47,,,fee schedule,,,48.47,,,fee schedule,,,47.5,,,fee schedule,,,,,,,,,80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF IV HYDRATION ADDL HR,2601367,CDM,260,RC,96361,CPT,5691,APC,,,,outpatient,facility,,,103,103,23.02,70.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,48.47,,,fee schedule,,,,,,,,,,,,,,,70.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,48.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,48.47,,,fee schedule,,,48.47,,,fee schedule,,,23.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INF IV THRPY 1ST HR,2601375,CDM,260,RC,96365,CPT,,,,,,inpatient,facility,,,468,196.56,397.8,449.28,,397.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,407.16,,,percent of total billed charges,,,,,,,,,421.2,,,percent of total billed charges,,,449.28,,,percent of total billed charges,,,444.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,435.24,,,percent of total billed charges,,,444.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF IV THRPY 1ST HR,2601375,CDM,260,RC,96365,CPT,,,,,,outpatient,facility,,,468,196.56,126.36,449.28,,397.8,,,percent of total billed charges,,,126.36,,,percent of total billed charges,,,321.98,,,percent of total billed charges,,,314.96,,,percent of total billed charges,,,395.46,,,percent of total billed charges,,,,,,,,,407.16,,,percent of total billed charges,,,407.16,,,percent of total billed charges,,,397.8,,,percent of total billed charges,,,449.28,,,percent of total billed charges,,,444.6,,,percent of total billed charges,,,,,,,,,421.2,,,percent of total billed charges,,,,,,,,,435.24,,,percent of total billed charges,,,444.6,,,percent of total billed charges,,,,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,214.35,,,fee schedule,,,,,,,,,365.51,,,percent of total billed charges,,,425.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF IV THRPY 1ST HR,2601375,CDM,260,RC,96365,CPT,5693,APC,,,,outpatient,facility,,,468,468,112.21,317.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,317.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",295.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,218.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,112.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INF IV THRPY ADDL HR,2601383,CDM,260,RC,96366,CPT,,,,,,inpatient,facility,,,127,53.34,107.95,121.92,,107.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.49,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF IV THRPY ADDL HR,2601383,CDM,260,RC,96366,CPT,,,,,,outpatient,facility,,,127,53.34,34.29,121.92,,107.95,,,percent of total billed charges,,,34.29,,,percent of total billed charges,,,87.38,,,percent of total billed charges,,,85.47,,,percent of total billed charges,,,107.31,,,percent of total billed charges,,,,,,,,,110.49,,,percent of total billed charges,,,110.49,,,percent of total billed charges,,,107.95,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,48.47,,,fee schedule,,,48.47,,,fee schedule,,,47.5,,,fee schedule,,,,,,,,,99.19,,,percent of total billed charges,,,115.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF IV THRPY ADDL HR,2601383,CDM,260,RC,96366,CPT,5691,APC,,,,outpatient,facility,,,127,127,23.02,70.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,48.47,,,fee schedule,,,,,,,,,,,,,,,70.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,48.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,48.47,,,fee schedule,,,48.47,,,fee schedule,,,23.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INF IV THRPY CONCURRENT,2601409,CDM,260,RC,96368,CPT,,,,,,inpatient,facility,,,401,168.42,340.85,384.96,,340.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.87,,,percent of total billed charges,,,,,,,,,360.9,,,percent of total billed charges,,,384.96,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,372.93,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF IV THRPY CONCURRENT,2601409,CDM,260,RC,96368,CPT,,,,,,outpatient,facility,,,401,168.42,108.27,401,,340.85,,,percent of total billed charges,,,108.27,,,percent of total billed charges,,,275.89,,,percent of total billed charges,,,269.87,,,percent of total billed charges,,,338.84,,,percent of total billed charges,,,,,,,,,348.87,,,percent of total billed charges,,,348.87,,,percent of total billed charges,,,340.85,,,percent of total billed charges,,,384.96,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,360.9,,,percent of total billed charges,,,,,,,,,372.93,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,,,,,,,401,,,fee schedule,,,401,,,fee schedule,,,401,,,fee schedule,,,,,,,,,313.18,,,percent of total billed charges,,,364.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF CASIRIV ANDIMDEV W POST MNTR,2602415,CDM,260,RC,M0243,HCPCS,,,,,,inpatient,facility,,,552,231.84,469.2,529.92,,469.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.24,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF CASIRIV ANDIMDEV W POST MNTR,2602415,CDM,260,RC,M0243,HCPCS,,,,,,outpatient,facility,,,552,231.84,149.04,529.92,,469.2,,,percent of total billed charges,,,149.04,,,percent of total billed charges,,,379.78,,,percent of total billed charges,,,371.5,,,percent of total billed charges,,,466.44,,,percent of total billed charges,,,,,,,,,480.24,,,percent of total billed charges,,,480.24,,,percent of total billed charges,,,469.2,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,482.49,,,fee schedule,,,482.49,,,fee schedule,,,472.84,,,fee schedule,,,,,,,,,431.11,,,percent of total billed charges,,,502.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF CASIRIV ANDIMDEV W POST MNTR,2602415,CDM,260,RC,M0243,HCPCS,1506,APC,,,,outpatient,facility,,,552,552,244.71,699.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,482.49,,,fee schedule,,,,,,,,,,,,,,,699.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",651.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,482.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,482.49,,,fee schedule,,,482.49,,,fee schedule,,,244.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INF BAMLANIV ANDETESEV W POST MNTR,2602449,CDM,260,RC,M0245,HCPCS,,,,,,inpatient,facility,,,552,231.84,469.2,529.92,,469.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.24,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF BAMLANIV ANDETESEV W POST MNTR,2602449,CDM,260,RC,M0245,HCPCS,,,,,,outpatient,facility,,,552,231.84,149.04,529.92,,469.2,,,percent of total billed charges,,,149.04,,,percent of total billed charges,,,379.78,,,percent of total billed charges,,,371.5,,,percent of total billed charges,,,466.44,,,percent of total billed charges,,,,,,,,,480.24,,,percent of total billed charges,,,480.24,,,percent of total billed charges,,,469.2,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,482.49,,,fee schedule,,,482.49,,,fee schedule,,,472.84,,,fee schedule,,,,,,,,,431.11,,,percent of total billed charges,,,502.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF BAMLANIV ANDETESEV W POST MNTR,2602449,CDM,260,RC,M0245,HCPCS,1506,APC,,,,outpatient,facility,,,552,552,244.71,699.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,482.49,,,fee schedule,,,,,,,,,,,,,,,699.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",651.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,482.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,482.49,,,fee schedule,,,482.49,,,fee schedule,,,244.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INF SOTROVIMAB W POST MNTR,2602498,CDM,260,RC,M0247,HCPCS,,,,,,inpatient,facility,,,552,231.84,469.2,529.92,,469.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,480.24,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INF SOTROVIMAB W POST MNTR,2602498,CDM,260,RC,M0247,HCPCS,,,,,,outpatient,facility,,,552,231.84,149.04,529.92,,469.2,,,percent of total billed charges,,,149.04,,,percent of total billed charges,,,379.78,,,percent of total billed charges,,,371.5,,,percent of total billed charges,,,466.44,,,percent of total billed charges,,,,,,,,,480.24,,,percent of total billed charges,,,480.24,,,percent of total billed charges,,,469.2,,,percent of total billed charges,,,529.92,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,496.8,,,percent of total billed charges,,,,,,,,,513.36,,,percent of total billed charges,,,524.4,,,percent of total billed charges,,,,,,,,,,,,,,,482.49,,,fee schedule,,,482.49,,,fee schedule,,,472.84,,,fee schedule,,,,,,,,,431.11,,,percent of total billed charges,,,502.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INF SOTROVIMAB W POST MNTR,2602498,CDM,260,RC,M0247,HCPCS,1506,APC,,,,outpatient,facility,,,552,552,244.71,699.61,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,482.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,492.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,482.49,,,fee schedule,,,,,,,,,,,,,,,699.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",651.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,482.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,482.49,,,fee schedule,,,482.49,,,fee schedule,,,244.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD OBSTETRICS PVT,273,CDM,112,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ADPT EXT LD PACING NEURO LVL 02,2770006,CDM,278,RC,C1883,HCPCS,,,,,,inpatient,facility,,,4397,1846.74,3737.45,4221.12,,3737.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3825.39,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ADPT EXT LD PACING NEURO LVL 02,2770006,CDM,278,RC,C1883,HCPCS,,,,,,outpatient,facility,,,4397,1846.74,1187.19,4397,,3737.45,,,percent of total billed charges,,,1187.19,,,percent of total billed charges,,,3025.14,,,percent of total billed charges,,,2959.18,,,percent of total billed charges,,,3715.46,,,percent of total billed charges,,,,,,,,,3825.39,,,percent of total billed charges,,,3825.39,,,percent of total billed charges,,,3737.45,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,4397,,,fee schedule,,,4397,,,fee schedule,,,4397,,,fee schedule,,,,,,,,,3434.06,,,percent of total billed charges,,,4001.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLIP APPLIER LVL 01,2770055,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLIP APPLIER LVL 01,2770055,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLIP APPLIER LVL 02,2770063,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLIP APPLIER LVL 02,2770063,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BIT LVL 03,2770170,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BIT LVL 03,2770170,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 07,2770287,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 07,2770287,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HYPO HYPER THERMAL LVL 01,2770329,CDM,271,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HYPO HYPER THERMAL LVL 01,2770329,CDM,271,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BOLT LVL 01,2770337,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,709,297.78,602.65,680.64,,602.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.83,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BOLT LVL 01,2770337,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,709,297.78,191.43,709,,602.65,,,percent of total billed charges,,,191.43,,,percent of total billed charges,,,487.79,,,percent of total billed charges,,,477.16,,,percent of total billed charges,,,599.11,,,percent of total billed charges,,,,,,,,,616.83,,,percent of total billed charges,,,616.83,,,percent of total billed charges,,,602.65,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,709,,,fee schedule,,,709,,,fee schedule,,,709,,,fee schedule,,,,,,,,,553.73,,,percent of total billed charges,,,645.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BOLT LVL 02,2770345,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BOLT LVL 02,2770345,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 01,2770352,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 01,2770352,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 02,2770360,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 02,2770360,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 03,2770378,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 03,2770378,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 04,2770386,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 04,2770386,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 09,2770394,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 09,2770394,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 05,2770402,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 05,2770402,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 06,2770410,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 06,2770410,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 07,2770428,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 07,2770428,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 08,2770436,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 08,2770436,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 10,2770444,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BONE HUMAN SYNTHETIC LVL 10,2770444,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BOWL CELL SAVER LVL 01,2770451,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BOWL CELL SAVER LVL 01,2770451,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRA SURG POSTOP LVL 02,2770469,CDM,271,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRA SURG POSTOP LVL 02,2770469,CDM,271,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRUSH LVL 02,2770477,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRUSH LVL 02,2770477,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRUSH LVL 01,2770485,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRUSH LVL 01,2770485,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP AGENT COLLAGN BULK 2.5ML LVL 06,2770493,CDM,278,RC,L8603,HCPCS,,,,,,inpatient,facility,,,20152,8463.84,17129.2,19345.92,,17129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17532.24,,,percent of total billed charges,,,,,,,,,18136.8,,,percent of total billed charges,,,19345.92,,,percent of total billed charges,,,19144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18741.36,,,percent of total billed charges,,,19144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP AGENT COLLAGN BULK 2.5ML LVL 06,2770493,CDM,278,RC,L8603,HCPCS,,,,,,outpatient,facility,,,20152,8463.84,5441.04,20152,,17129.2,,,percent of total billed charges,,,5441.04,,,percent of total billed charges,,,13864.58,,,percent of total billed charges,,,13562.3,,,percent of total billed charges,,,17028.44,,,percent of total billed charges,,,,,,,,,17532.24,,,percent of total billed charges,,,17532.24,,,percent of total billed charges,,,17129.2,,,percent of total billed charges,,,19345.92,,,percent of total billed charges,,,19144.4,,,percent of total billed charges,,,,,,,,,18136.8,,,percent of total billed charges,,,,,,,,,18741.36,,,percent of total billed charges,,,19144.4,,,percent of total billed charges,,,,,,,,,,,,,,,20152,,,fee schedule,,,20152,,,fee schedule,,,20152,,,fee schedule,,,,,,,,,15738.71,,,percent of total billed charges,,Paid in addition to outpatient services ,18338.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP AGENT SYNTHETIC BULK 1ML LVL 01,2770501,CDM,278,RC,L8606,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP AGENT SYNTHETIC BULK 1ML LVL 01,2770501,CDM,278,RC,L8606,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BURR LVL 01,2770519,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BURR LVL 01,2770519,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BURR LVL 02,2770527,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BURR LVL 02,2770527,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BURR LVL 03,2770535,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BURR LVL 03,2770535,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BURR LVL 04,2770543,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BURR LVL 04,2770543,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BURR LVL 05,2770550,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BURR LVL 05,2770550,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BURR LVL 06,2770568,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BURR LVL 06,2770568,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 01,2770584,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 01,2770584,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 02,2770592,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,844,354.48,717.4,810.24,,717.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,734.28,,,percent of total billed charges,,,,,,,,,759.6,,,percent of total billed charges,,,810.24,,,percent of total billed charges,,,801.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,784.92,,,percent of total billed charges,,,801.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 02,2770592,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,844,354.48,227.88,844,,717.4,,,percent of total billed charges,,,227.88,,,percent of total billed charges,,,580.67,,,percent of total billed charges,,,568.01,,,percent of total billed charges,,,713.18,,,percent of total billed charges,,,,,,,,,734.28,,,percent of total billed charges,,,734.28,,,percent of total billed charges,,,717.4,,,percent of total billed charges,,,810.24,,,percent of total billed charges,,,801.8,,,percent of total billed charges,,,,,,,,,759.6,,,percent of total billed charges,,,,,,,,,784.92,,,percent of total billed charges,,,801.8,,,percent of total billed charges,,,,,,,,,,,,,,,844,,,fee schedule,,,844,,,fee schedule,,,844,,,fee schedule,,,,,,,,,659.16,,,percent of total billed charges,,,768.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 03,2770600,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 03,2770600,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 04,2770618,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 04,2770618,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 05,2770626,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 05,2770626,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 01,2770634,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 01,2770634,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 02,2770642,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 02,2770642,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 03,2770659,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 03,2770659,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 04,2770667,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 04,2770667,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 05,2770675,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 05,2770675,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 05,2770683,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CANNULA LVL 05,2770683,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 08,2770691,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,35044,14718.48,29787.4,33642.24,,29787.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30488.28,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 08,2770691,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,35044,14718.48,9461.88,35044,,29787.4,,,percent of total billed charges,,,9461.88,,,percent of total billed charges,,,24110.27,,,percent of total billed charges,,,23584.61,,,percent of total billed charges,,,29612.18,,,percent of total billed charges,,,,,,,,,30488.28,,,percent of total billed charges,,,30488.28,,,percent of total billed charges,,,29787.4,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,35044,,,fee schedule,,,35044,,,fee schedule,,,35044,,,fee schedule,,,,,,,,,27369.36,,,percent of total billed charges,,Paid in addition to outpatient services ,31890.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 09,2770709,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,39424,16558.08,33510.4,37847.04,,33510.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34298.88,,,percent of total billed charges,,,,,,,,,35481.6,,,percent of total billed charges,,,37847.04,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36664.32,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 09,2770709,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,39424,16558.08,10644.48,39424,,33510.4,,,percent of total billed charges,,,10644.48,,,percent of total billed charges,,,27123.71,,,percent of total billed charges,,,26532.35,,,percent of total billed charges,,,33313.28,,,percent of total billed charges,,,,,,,,,34298.88,,,percent of total billed charges,,,34298.88,,,percent of total billed charges,,,33510.4,,,percent of total billed charges,,,37847.04,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,35481.6,,,percent of total billed charges,,,,,,,,,36664.32,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,,,,,,,39424,,,fee schedule,,,39424,,,fee schedule,,,39424,,,fee schedule,,,,,,,,,30790.14,,,percent of total billed charges,,Paid in addition to outpatient services ,35875.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 10,2770725,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 10,2770725,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,Paid in addition to outpatient services ,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 04,2770733,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 04,2770733,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL COOL TIP LVL 05,2770741,CDM,272,RC,C2630,HCPCS,,,,,,inpatient,facility,,,5861,2461.62,4981.85,5626.56,,4981.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5099.07,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL COOL TIP LVL 05,2770741,CDM,272,RC,C2630,HCPCS,,,,,,outpatient,facility,,,5861,2461.62,1582.47,5861,,4981.85,,,percent of total billed charges,,,1582.47,,,percent of total billed charges,,,4032.37,,,percent of total billed charges,,,3944.45,,,percent of total billed charges,,,4952.55,,,percent of total billed charges,,,,,,,,,5099.07,,,percent of total billed charges,,,5099.07,,,percent of total billed charges,,,4981.85,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,5861,,,fee schedule,,,5861,,,fee schedule,,,5861,,,fee schedule,,,,,,,,,,,,,,,5333.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 01,2770758,CDM,272,RC,C1732,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 01,2770758,CDM,272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,,,,,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 01,2770766,CDM,272,RC,C1733,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 01,2770766,CDM,272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,,,,,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL LASER LVL 01,2770774,CDM,272,RC,C1885,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL LASER LVL 01,2770774,CDM,272,RC,C1885,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 01,2770782,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 01,2770782,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL DIRECT LVL 01,2770790,CDM,272,RC,C1714,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL DIRECT LVL 01,2770790,CDM,272,RC,C1714,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL ROTAT LVL 01,2770808,CDM,272,RC,C1724,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL ROTAT LVL 01,2770808,CDM,272,RC,C1724,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 01,2770816,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 01,2770816,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 01,2770824,CDM,272,RC,C1726,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 01,2770824,CDM,272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,,,,,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON TISS DIS NONVAS LVL 01,2770832,CDM,272,RC,C1727,HCPCS,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON TISS DIS NONVAS LVL 01,2770832,CDM,272,RC,C1727,HCPCS,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,,,,,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 01,2770857,CDM,272,RC,,,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 01,2770857,CDM,272,RC,,,,,,,,outpatient,facility,,,102,42.84,27.54,102,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,102,,,fee schedule,,,102,,,fee schedule,,,102,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 01,2770865,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 01,2770865,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 01,2770873,CDM,272,RC,C1730,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 01,2770873,CDM,272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 20 PLUS LVL 01,2770881,CDM,272,RC,C1731,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 20 PLUS LVL 01,2770881,CDM,272,RC,C1731,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,,,,,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ENDOBRONCHIAL LVL 01,2770899,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ENDOBRONCHIAL LVL 01,2770899,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH FEEDING LVL 01,2770907,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH FEEDING LVL 01,2770907,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 01,2770915,CDM,272,RC,C1887,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 01,2770915,CDM,272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,,,,,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 01,2770923,CDM,272,RC,C1752,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 01,2770923,CDM,272,RC,C1752,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 01,2770931,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 01,2770931,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH HYDROPHYLIC LVL 01,2770949,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH HYDROPHYLIC LVL 01,2770949,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 01,2770956,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 01,2770956,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRACARDIAC ECHO LVL 02,2770964,CDM,272,RC,C1759,HCPCS,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRACARDIAC ECHO LVL 02,2770964,CDM,272,RC,C1759,HCPCS,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,,,,,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRASPINAL LVL 04,2770980,CDM,272,RC,C1755,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRASPINAL LVL 04,2770980,CDM,272,RC,C1755,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,,,,,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAVASCULAR US LVL 01,2770998,CDM,272,RC,C1753,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAVASCULAR US LVL 01,2770998,CDM,272,RC,C1753,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 01,2771012,CDM,272,RC,C2628,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 01,2771012,CDM,272,RC,C2628,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 01,2771020,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 01,2771020,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 01,2771046,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 01,2771046,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 01,2771053,CDM,272,RC,C2627,HCPCS,,,,,,inpatient,facility,,,251,105.42,213.35,240.96,,213.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,percent of total billed charges,,,,,,,,,225.9,,,percent of total billed charges,,,240.96,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,233.43,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 01,2771053,CDM,272,RC,C2627,HCPCS,,,,,,outpatient,facility,,,251,105.42,67.77,251,,213.35,,,percent of total billed charges,,,67.77,,,percent of total billed charges,,,172.69,,,percent of total billed charges,,,168.92,,,percent of total billed charges,,,212.09,,,percent of total billed charges,,,,,,,,,218.37,,,percent of total billed charges,,,218.37,,,percent of total billed charges,,,213.35,,,percent of total billed charges,,,240.96,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,225.9,,,percent of total billed charges,,,,,,,,,233.43,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,,,,,,,251,,,fee schedule,,,251,,,fee schedule,,,251,,,fee schedule,,,,,,,,,196.03,,,percent of total billed charges,,,228.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 01,2771061,CDM,272,RC,C1757,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 01,2771061,CDM,272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 01,2771079,CDM,272,RC,C1758,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 01,2771079,CDM,272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 02,2771087,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 02,2771087,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 01,2771095,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 01,2771095,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 02,2771103,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 02,2771103,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 03,2771111,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 03,2771111,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 04,2771129,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 04,2771129,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 11,2771137,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,52564,22076.88,44679.4,50461.44,,44679.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45730.68,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 11,2771137,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,52564,22076.88,14192.28,52564,,44679.4,,,percent of total billed charges,,,14192.28,,,percent of total billed charges,,,36164.03,,,percent of total billed charges,,,35375.57,,,percent of total billed charges,,,44416.58,,,percent of total billed charges,,,,,,,,,45730.68,,,percent of total billed charges,,,45730.68,,,percent of total billed charges,,,44679.4,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,52564,,,fee schedule,,,52564,,,fee schedule,,,52564,,,fee schedule,,,,,,,,,41052.48,,,percent of total billed charges,,Paid in addition to outpatient services ,47833.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 05,2771145,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 05,2771145,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 06,2771152,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 06,2771152,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 07,2771160,CDM,272,RC,,,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 07,2771160,CDM,272,RC,,,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,1474.53,,,percent of total billed charges,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 08,2771178,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ELECTRODE ELECTROSURGICAL LVL 08,2771178,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 04,2771186,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 04,2771186,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 01,2771194,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 01,2771194,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CEMENT ACCESSORIES LVL 01,2771202,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT ACCESSORIES LVL 01,2771202,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CEMENT ACCESSORY LVL 01,2771210,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CEMENT ACCESSORY LVL 01,2771210,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 02,2771228,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 02,2771228,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 03,2771236,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 03,2771236,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 01,2771244,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 01,2771244,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 02,2771251,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 02,2771251,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 03,2771269,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 03,2771269,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLIP LVL 01,2771277,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLIP LVL 01,2771277,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CLIP ANEURYSM LVL 01,2771285,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CLIP ANEURYSM LVL 01,2771285,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 01,2771301,CDM,278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 01,2771301,CDM,278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 01,2771319,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 01,2771319,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
COIL IMAGING MAGNETIC RESON LVL 01,2771327,CDM,272,RC,C1770,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
COIL IMAGING MAGNETIC RESON LVL 01,2771327,CDM,272,RC,C1770,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY COLD LVL 02,2771335,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY COLD LVL 02,2771335,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COVER BURR HOLE LVL 02,2771343,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COVER BURR HOLE LVL 02,2771343,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 02,2771350,CDM,272,RC,C1733,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 02,2771350,CDM,272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,,,,,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 03,2771368,CDM,272,RC,C1733,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 03,2771368,CDM,272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 04,2771376,CDM,272,RC,C1733,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP NO3D VECTOR LVL 04,2771376,CDM,272,RC,C1733,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL LASER LVL 02,2771384,CDM,272,RC,C1885,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL LASER LVL 02,2771384,CDM,272,RC,C1885,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ACCESS SYSTEM DIALYS LVL 01,2771400,CDM,278,RC,C1881,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ACCESS SYSTEM DIALYS LVL 01,2771400,CDM,278,RC,C1881,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 01,2771418,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 01,2771418,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 01,2771426,CDM,272,RC,27714261000,NDC,,,,,,inpatient,facility,1,EA,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 01,2771426,CDM,272,RC,27714261000,NDC,,,,,,outpatient,facility,1,EA,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 02,2771434,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 02,2771434,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 03,2771442,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 03,2771442,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 04,2771459,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 04,2771459,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 05,2771467,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DILATOR LVL 05,2771467,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 02,2771475,CDM,272,RC,,,,,,,,inpatient,facility,,,134,56.28,113.9,128.64,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.58,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 02,2771475,CDM,272,RC,,,,,,,,outpatient,facility,,,134,56.28,36.18,134,,113.9,,,percent of total billed charges,,,36.18,,,percent of total billed charges,,,92.19,,,percent of total billed charges,,,90.18,,,percent of total billed charges,,,113.23,,,percent of total billed charges,,,,,,,,,116.58,,,percent of total billed charges,,,116.58,,,percent of total billed charges,,,113.9,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,134,,,fee schedule,,,134,,,fee schedule,,,134,,,fee schedule,,,,,,,,,104.65,,,percent of total billed charges,,,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 03,2771483,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 03,2771483,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 04,2771491,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 04,2771491,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 05,2771509,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN LVL 05,2771509,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCH LVL 02,2771517,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCH LVL 02,2771517,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR NEURO LVL 02,2771525,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR NEURO LVL 02,2771525,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 01,2771533,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 01,2771533,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 01,2771558,CDM,272,RC,,,,,,,,inpatient,facility,,,190,79.8,161.5,182.4,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.3,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 01,2771558,CDM,272,RC,,,,,,,,outpatient,facility,,,190,79.8,51.3,190,,161.5,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,130.72,,,percent of total billed charges,,,127.87,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,,,,,,,165.3,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,190,,,fee schedule,,,190,,,fee schedule,,,190,,,fee schedule,,,,,,,,,148.39,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 02,2771566,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 02,2771566,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 03,2771574,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 03,2771574,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 04,2771582,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 04,2771582,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 05,2771590,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 05,2771590,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 06,2771608,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 06,2771608,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 19,2771616,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,87604,36793.68,74463.4,84099.84,,74463.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76215.48,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 19,2771616,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,87604,36793.68,23653.08,87604,,74463.4,,,percent of total billed charges,,,23653.08,,,percent of total billed charges,,,60271.55,,,percent of total billed charges,,,58957.49,,,percent of total billed charges,,,74025.38,,,percent of total billed charges,,,,,,,,,76215.48,,,percent of total billed charges,,,76215.48,,,percent of total billed charges,,,74463.4,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,87604,,,fee schedule,,,87604,,,fee schedule,,,87604,,,fee schedule,,,,,,,,,68418.72,,,percent of total billed charges,,Paid in addition to outpatient services ,79719.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 02,2771624,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 02,2771624,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EXPANDER TISSUE LVL 01,2771632,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2426,1018.92,2062.1,2328.96,,2062.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2110.62,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EXPANDER TISSUE LVL 01,2771632,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2426,1018.92,655.02,2426,,2062.1,,,percent of total billed charges,,,655.02,,,percent of total billed charges,,,1669.09,,,percent of total billed charges,,,1632.7,,,percent of total billed charges,,,2049.97,,,percent of total billed charges,,,,,,,,,2110.62,,,percent of total billed charges,,,2110.62,,,percent of total billed charges,,,2062.1,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,2426,,,fee schedule,,,2426,,,fee schedule,,,2426,,,fee schedule,,,,,,,,,1894.71,,,percent of total billed charges,,,2207.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EXPANDER TISSUE LVL 02,2771640,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EXPANDER TISSUE LVL 02,2771640,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EXPANDER TISSUE LVL 03,2771657,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EXPANDER TISSUE LVL 03,2771657,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 02,2771673,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 02,2771673,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,,,,,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 03,2771681,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 03,2771681,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,,,,,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 04,2771699,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 04,2771699,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 05,2771707,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 05,2771707,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,,,,,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 20 PLUS LVL 02,2771715,CDM,272,RC,C1731,HCPCS,,,,,,inpatient,facility,,,5861,2461.62,4981.85,5626.56,,4981.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5099.07,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 20 PLUS LVL 02,2771715,CDM,272,RC,C1731,HCPCS,,,,,,outpatient,facility,,,5861,2461.62,1582.47,5861,,4981.85,,,percent of total billed charges,,,1582.47,,,percent of total billed charges,,,4032.37,,,percent of total billed charges,,,3944.45,,,percent of total billed charges,,,4952.55,,,percent of total billed charges,,,,,,,,,5099.07,,,percent of total billed charges,,,5099.07,,,percent of total billed charges,,,4981.85,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,5861,,,fee schedule,,,5861,,,fee schedule,,,5861,,,fee schedule,,,,,,,,,,,,,,,5333.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 06,2771723,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,4397,1846.74,3737.45,4221.12,,3737.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3825.39,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 06,2771723,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,4397,1846.74,1187.19,4397,,3737.45,,,percent of total billed charges,,,1187.19,,,percent of total billed charges,,,3025.14,,,percent of total billed charges,,,2959.18,,,percent of total billed charges,,,3715.46,,,percent of total billed charges,,,,,,,,,3825.39,,,percent of total billed charges,,,3825.39,,,percent of total billed charges,,,3737.45,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,4397,,,fee schedule,,,4397,,,fee schedule,,,4397,,,fee schedule,,,,,,,,,,,,,,,4001.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 07,2771731,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,5861,2461.62,4981.85,5626.56,,4981.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5099.07,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 07,2771731,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,5861,2461.62,1582.47,5861,,4981.85,,,percent of total billed charges,,,1582.47,,,percent of total billed charges,,,4032.37,,,percent of total billed charges,,,3944.45,,,percent of total billed charges,,,4952.55,,,percent of total billed charges,,,,,,,,,5099.07,,,percent of total billed charges,,,5099.07,,,percent of total billed charges,,,4981.85,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,5861,,,fee schedule,,,5861,,,fee schedule,,,5861,,,fee schedule,,,,,,,,,,,,,,,5333.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 08,2771749,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,7413,3113.46,6301.05,7116.48,,6301.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6449.31,,,percent of total billed charges,,,,,,,,,6671.7,,,percent of total billed charges,,,7116.48,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6894.09,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 08,2771749,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,7413,3113.46,2001.51,7413,,6301.05,,,percent of total billed charges,,,2001.51,,,percent of total billed charges,,,5100.14,,,percent of total billed charges,,,4988.95,,,percent of total billed charges,,,6263.98,,,percent of total billed charges,,,,,,,,,6449.31,,,percent of total billed charges,,,6449.31,,,percent of total billed charges,,,6301.05,,,percent of total billed charges,,,7116.48,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,6671.7,,,percent of total billed charges,,,,,,,,,6894.09,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,,,,,,,7413,,,fee schedule,,,7413,,,fee schedule,,,7413,,,fee schedule,,,,,,,,,,,,,,,6745.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 09,2771756,CDM,272,RC,C1725,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL NONLASER LVL 09,2771756,CDM,272,RC,C1725,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH FEEDING LVL 02,2771764,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH FEEDING LVL 02,2771764,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 02,2771772,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 02,2771772,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 03,2771780,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 03,2771780,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 04,2771798,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 04,2771798,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,,,,,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 05,2771806,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 05,2771806,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,,,,,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 06,2771814,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 06,2771814,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 07,2771822,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 07,2771822,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 08,2771830,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 08,2771830,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,,,,,,,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 09,2771848,CDM,272,RC,C1751,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INF NON HEMODIALYSIS LVL 09,2771848,CDM,272,RC,C1751,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 02,2771855,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 02,2771855,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAVASCULAR US LVL 03,2771863,CDM,272,RC,C1753,HCPCS,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAVASCULAR US LVL 03,2771863,CDM,272,RC,C1753,HCPCS,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,,,,,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 03,2771871,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 03,2771871,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 04,2771889,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 04,2771889,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 05,2771897,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 05,2771897,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAVASCULAR US LVL 02,2771905,CDM,272,RC,C1753,HCPCS,,,,,,inpatient,facility,,,2426,1018.92,2062.1,2328.96,,2062.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2110.62,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAVASCULAR US LVL 02,2771905,CDM,272,RC,C1753,HCPCS,,,,,,outpatient,facility,,,2426,1018.92,655.02,2426,,2062.1,,,percent of total billed charges,,,655.02,,,percent of total billed charges,,,1669.09,,,percent of total billed charges,,,1632.7,,,percent of total billed charges,,,2049.97,,,percent of total billed charges,,,,,,,,,2110.62,,,percent of total billed charges,,,2110.62,,,percent of total billed charges,,,2062.1,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,2426,,,fee schedule,,,2426,,,fee schedule,,,2426,,,fee schedule,,,,,,,,,,,,,,,2207.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 02,2771921,CDM,272,RC,C2628,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 02,2771921,CDM,272,RC,C2628,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,,,,,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 03,2771939,CDM,272,RC,C2628,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 03,2771939,CDM,272,RC,C2628,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 04,2771947,CDM,272,RC,C2628,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 04,2771947,CDM,272,RC,C2628,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 05,2771954,CDM,272,RC,C2628,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 05,2771954,CDM,272,RC,C2628,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 06,2771962,CDM,272,RC,C2628,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH OCCLUSION LVL 06,2771962,CDM,272,RC,C2628,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,,,,,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 03,2771970,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 03,2771970,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 04,2771988,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON PACING LVL 04,2771988,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 02,2771996,CDM,272,RC,,,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 02,2771996,CDM,272,RC,,,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,1474.53,,,percent of total billed charges,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION AGENT LVL 01,2772002,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION AGENT LVL 01,2772002,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 03,2772010,CDM,272,RC,,,,,,,,inpatient,facility,,,2827,1187.34,2402.95,2713.92,,2402.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2459.49,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 03,2772010,CDM,272,RC,,,,,,,,outpatient,facility,,,2827,1187.34,763.29,2827,,2402.95,,,percent of total billed charges,,,763.29,,,percent of total billed charges,,,1944.98,,,percent of total billed charges,,,1902.57,,,percent of total billed charges,,,2388.82,,,percent of total billed charges,,,,,,,,,2459.49,,,percent of total billed charges,,,2459.49,,,percent of total billed charges,,,2402.95,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,2827,,,fee schedule,,,2827,,,fee schedule,,,2827,,,fee schedule,,,,,,,,,2207.89,,,percent of total billed charges,,,2572.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 04,2772028,CDM,272,RC,,,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SPINAL NEURO LVL 04,2772028,CDM,272,RC,,,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 03,2772036,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 03,2772036,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 07,2772044,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,30664,12878.88,26064.4,29437.44,,26064.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26677.68,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 07,2772044,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,30664,12878.88,8279.28,30664,,26064.4,,,percent of total billed charges,,,8279.28,,,percent of total billed charges,,,21096.83,,,percent of total billed charges,,,20636.87,,,percent of total billed charges,,,25911.08,,,percent of total billed charges,,,,,,,,,26677.68,,,percent of total billed charges,,,26677.68,,,percent of total billed charges,,,26064.4,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,30664,,,fee schedule,,,30664,,,fee schedule,,,30664,,,fee schedule,,,,,,,,,23948.58,,,percent of total billed charges,,Paid in addition to outpatient services ,27904.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FILTER VENA CAVA LVL 03,2772119,CDM,278,RC,C1880,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FILTER VENA CAVA LVL 03,2772119,CDM,278,RC,C1880,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 01,2772127,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 01,2772127,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 02,2772135,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 02,2772135,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 01,2772143,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 01,2772143,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 02,2772150,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 02,2772150,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 03,2772168,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 03,2772168,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 04,2772176,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 04,2772176,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 09,2772184,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 09,2772184,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 05,2772192,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 05,2772192,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 06,2772200,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 06,2772200,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 07,2772218,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 07,2772218,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 08,2772226,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 08,2772226,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 10,2772234,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 10,2772234,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PIN GUIDE LVL 01,2772242,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE LVL 01,2772242,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PIN GUIDE LVL 02,2772259,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE LVL 02,2772259,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PIN GUIDE LVL 03,2772267,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PIN GUIDE LVL 03,2772267,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 01,2772275,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 01,2772275,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,,,,,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 02,2772283,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 02,2772283,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 03,2772291,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 03,2772291,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 01,2772309,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 01,2772309,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 02,2772317,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 02,2772317,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 03,2772325,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 03,2772325,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HARVESTER LVL 01,2772333,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HARVESTER LVL 01,2772333,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 01,2772341,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 01,2772341,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 02,2772358,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 02,2772358,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 03,2772366,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 03,2772366,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER NON SGL DUAL LVL 04,2772374,CDM,278,RC,C1882,HCPCS,,,,,,inpatient,facility,,,96364,40472.88,81909.4,92509.44,,81909.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83836.68,,,percent of total billed charges,,,,,,,,,86727.6,,,percent of total billed charges,,,92509.44,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89618.52,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER NON SGL DUAL LVL 04,2772374,CDM,278,RC,C1882,HCPCS,,,,,,outpatient,facility,,,96364,40472.88,26018.28,96364,,81909.4,,,percent of total billed charges,,,26018.28,,,percent of total billed charges,,,66298.43,,,percent of total billed charges,,,64852.97,,,percent of total billed charges,,,81427.58,,,percent of total billed charges,,,,,,,,,83836.68,,,percent of total billed charges,,,83836.68,,,percent of total billed charges,,,81909.4,,,percent of total billed charges,,,92509.44,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,86727.6,,,percent of total billed charges,,,,,,,,,89618.52,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,,,,,,,96364,,,fee schedule,,,96364,,,fee schedule,,,96364,,,fee schedule,,,,,,,,,75260.28,,,percent of total billed charges,,Paid in addition to outpatient services ,87691.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER DUAL LVL 02,2772382,CDM,275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,65704,27595.68,55848.4,63075.84,,55848.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57162.48,,,percent of total billed charges,,,,,,,,,59133.6,,,percent of total billed charges,,,63075.84,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61104.72,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER DUAL LVL 02,2772382,CDM,275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,65704,27595.68,17740.08,65704,,55848.4,,,percent of total billed charges,,,17740.08,,,percent of total billed charges,,,45204.35,,,percent of total billed charges,,,44218.79,,,percent of total billed charges,,,55519.88,,,percent of total billed charges,,,,,,,,,57162.48,,,percent of total billed charges,,,57162.48,,,percent of total billed charges,,,55848.4,,,percent of total billed charges,,,63075.84,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,59133.6,,,percent of total billed charges,,,,,,,,,61104.72,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,65704,,,fee schedule,,,65704,,,fee schedule,,,65704,,,fee schedule,,,,,,,,,51314.82,,,percent of total billed charges,,Paid in addition to outpatient services ,59790.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER SGL LVL 02,2772390,CDM,275,RC,C1722,HCPCS,,,,,,inpatient,facility,,,65704,27595.68,55848.4,63075.84,,55848.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57162.48,,,percent of total billed charges,,,,,,,,,59133.6,,,percent of total billed charges,,,63075.84,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61104.72,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER SGL LVL 02,2772390,CDM,275,RC,C1722,HCPCS,,,,,,outpatient,facility,,,65704,27595.68,17740.08,65704,,55848.4,,,percent of total billed charges,,,17740.08,,,percent of total billed charges,,,45204.35,,,percent of total billed charges,,,44218.79,,,percent of total billed charges,,,55519.88,,,percent of total billed charges,,,,,,,,,57162.48,,,percent of total billed charges,,,57162.48,,,percent of total billed charges,,,55848.4,,,percent of total billed charges,,,63075.84,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,59133.6,,,percent of total billed charges,,,,,,,,,61104.72,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,65704,,,fee schedule,,,65704,,,fee schedule,,,65704,,,fee schedule,,,,,,,,,51314.82,,,percent of total billed charges,,Paid in addition to outpatient services ,59790.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 01,2772408,CDM,271,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 01,2772408,CDM,271,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 02,2772416,CDM,271,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 02,2772416,CDM,271,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 03,2772424,CDM,271,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 03,2772424,CDM,271,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 04,2772432,CDM,271,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMMOBILIZER LVL 04,2772432,CDM,271,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR THORACIC LVL 02,2772440,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR THORACIC LVL 02,2772440,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 01,2772457,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 01,2772457,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSERTER LVL 01,2772465,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSERTER LVL 01,2772465,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSERTER LVL 02,2772473,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSERTER LVL 02,2772473,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSERTER LVL 03,2772481,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSERTER LVL 03,2772481,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV URINARY W SLING LVL 02,2772499,CDM,278,RC,C1771,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV URINARY W SLING LVL 02,2772499,CDM,278,RC,C1771,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV URINARY WO SLNG LVL 02,2772507,CDM,278,RC,C2631,HCPCS,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV URINARY WO SLNG LVL 02,2772507,CDM,278,RC,C2631,HCPCS,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 02,2772515,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 02,2772515,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 03,2772523,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 03,2772523,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 04,2772531,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 04,2772531,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 05,2772549,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 05,2772549,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 01,2772556,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 01,2772556,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 01,2772564,CDM,272,RC,,,,,,,,inpatient,facility,,,190,79.8,161.5,182.4,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.3,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 01,2772564,CDM,272,RC,,,,,,,,outpatient,facility,,,190,79.8,51.3,190,,161.5,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,130.72,,,percent of total billed charges,,,127.87,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,,,,,,,165.3,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,190,,,fee schedule,,,190,,,fee schedule,,,190,,,fee schedule,,,,,,,,,148.39,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 02,2772572,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 02,2772572,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 03,2772580,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 03,2772580,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 04,2772598,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 04,2772598,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 05,2772606,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 05,2772606,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 01,2772622,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 01,2772622,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 02,2772630,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 02,2772630,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 03,2772648,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 03,2772648,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 04,2772655,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 04,2772655,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 02,2772663,CDM,278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 02,2772663,CDM,278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 05,2772671,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 05,2772671,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 06,2772689,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 06,2772689,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 07,2772697,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 07,2772697,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 08,2772705,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX SPINE LVL 08,2772705,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 03,2772713,CDM,278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 03,2772713,CDM,278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 04,2772721,CDM,278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 04,2772721,CDM,278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 05,2772739,CDM,278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 05,2772739,CDM,278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 11,2772747,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 11,2772747,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 12,2772754,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 12,2772754,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 13,2772762,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 13,2772762,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO EP FIX CRV NONPEEL LVL 01,2772770,CDM,272,RC,C1893,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO EP FIX CRV NONPEEL LVL 01,2772770,CDM,272,RC,C1893,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO EP FIX CRV PEEL LVL 01,2772788,CDM,272,RC,C1892,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO EP FIX CRV PEEL LVL 01,2772788,CDM,272,RC,C1892,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 14,2772796,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 14,2772796,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO LVL 01,2772804,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO LVL 01,2772804,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO LVL 02,2772812,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO LVL 02,2772812,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO LVL 03,2772820,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO LVL 03,2772820,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 15,2772838,CDM,272,RC,,,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 15,2772838,CDM,272,RC,,,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO EP STEER NONPEEL LVL 03,2772846,CDM,272,RC,C1766,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO EP STEER NONPEEL LVL 03,2772846,CDM,272,RC,C1766,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TAPS LVL 03,2772853,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TAPS LVL 03,2772853,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TAPS LVL 02,2772861,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TAPS LVL 02,2772861,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 01,2772879,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 01,2772879,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 02,2772887,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 02,2772887,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 03,2772895,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 03,2772895,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KNOT PUSHER LVL 01,2772903,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KNOT PUSHER LVL 01,2772903,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 01,2772911,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 01,2772911,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 02,2772929,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 02,2772929,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 03,2772937,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 03,2772937,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 04,2772945,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 04,2772945,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 05,2772952,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 05,2772952,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 01,2772960,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 01,2772960,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 02,2772978,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 02,2772978,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 03,2772986,CDM,272,RC,,,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 03,2772986,CDM,272,RC,,,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 04,2772994,CDM,272,RC,,,,,,,,inpatient,facility,,,6105,2564.1,5189.25,5860.8,,5189.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5311.35,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 04,2772994,CDM,272,RC,,,,,,,,outpatient,facility,,,6105,2564.1,1648.35,6105,,5189.25,,,percent of total billed charges,,,1648.35,,,percent of total billed charges,,,4200.24,,,percent of total billed charges,,,4108.66,,,percent of total billed charges,,,5158.72,,,percent of total billed charges,,,,,,,,,5311.35,,,percent of total billed charges,,,5311.35,,,percent of total billed charges,,,5189.25,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,6105,,,fee schedule,,,6105,,,fee schedule,,,6105,,,fee schedule,,,,,,,,,4768,,,percent of total billed charges,,,5555.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 05,2773000,CDM,272,RC,,,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER PROBE LVL 05,2773000,CDM,272,RC,,,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10852,,,percent of total billed charges,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD ICD COIL DUAL LVL 01,2773018,CDM,278,RC,C1895,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD ICD COIL DUAL LVL 01,2773018,CDM,278,RC,C1895,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD ICD NON SGL DUAL LVL 04,2773026,CDM,278,RC,C1896,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD ICD NON SGL DUAL LVL 04,2773026,CDM,278,RC,C1896,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD ICD COIL SGL LVL 01,2773034,CDM,278,RC,C1777,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD ICD COIL SGL LVL 01,2773034,CDM,278,RC,C1777,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD NEUROSTIM LVL 01,2773042,CDM,278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD NEUROSTIM LVL 01,2773042,CDM,278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD NEUROSTIM TEST KIT LVL 06,2773059,CDM,278,RC,C1897,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD NEUROSTIM TEST KIT LVL 06,2773059,CDM,278,RC,C1897,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 01,2773067,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 01,2773067,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR NON VDD LVL 01,2773075,CDM,278,RC,C1898,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR NON VDD LVL 01,2773075,CDM,278,RC,C1898,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR VDD LVL 02,2773083,CDM,278,RC,C1779,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR VDD LVL 02,2773083,CDM,278,RC,C1779,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR NEW TECH LVL 02,2773125,CDM,276,RC,C1780,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR NEW TECH LVL 02,2773125,CDM,276,RC,C1780,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR NEW TECH LVL 03,2773133,CDM,276,RC,C1780,HCPCS,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LENS INTRAOCULAR NEW TECH LVL 03,2773133,CDM,276,RC,C1780,HCPCS,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 01,2773141,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 01,2773141,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MARKER TISSUE LVL 01,2773158,CDM,278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MARKER TISSUE LVL 01,2773158,CDM,278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 01,2773166,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 01,2773166,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 02,2773174,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 02,2773174,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 03,2773182,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 03,2773182,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 04,2773190,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 04,2773190,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 09,2773208,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 09,2773208,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 05,2773216,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 05,2773216,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 06,2773224,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 06,2773224,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 07,2773232,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 07,2773232,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 08,2773240,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 08,2773240,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 10,2773257,CDM,278,RC,C1781,HCPCS,,,,,,inpatient,facility,,,15334,6440.28,13033.9,14720.64,,13033.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13340.58,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MESH LVL 10,2773257,CDM,278,RC,C1781,HCPCS,,,,,,outpatient,facility,,,15334,6440.28,4140.18,15334,,13033.9,,,percent of total billed charges,,,4140.18,,,percent of total billed charges,,,10549.79,,,percent of total billed charges,,,10319.78,,,percent of total billed charges,,,12957.23,,,percent of total billed charges,,,,,,,,,13340.58,,,percent of total billed charges,,,13340.58,,,percent of total billed charges,,,13033.9,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,15334,,,fee schedule,,,15334,,,fee schedule,,,15334,,,fee schedule,,,,,,,,,11975.85,,,percent of total billed charges,,Paid in addition to outpatient services ,13953.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MORCELLATOR LVL 04,2773315,CDM,272,RC,C1782,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MORCELLATOR LVL 04,2773315,CDM,272,RC,C1782,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,,,,,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 01,2773331,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 01,2773331,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 02,2773349,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 02,2773349,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 03,2773356,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 03,2773356,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY LVL 01,2773364,CDM,272,RC,C1715,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE BRACHYTHERAPY LVL 01,2773364,CDM,272,RC,C1715,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,,,,,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE INSUFFLATION LVL 01,2773380,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE INSUFFLATION LVL 01,2773380,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE INSUFFLATION LVL 02,2773398,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE INSUFFLATION LVL 02,2773398,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 01,2773406,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 01,2773406,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 02,2773414,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 02,2773414,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 03,2773422,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 03,2773422,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 04,2773430,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 04,2773430,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 05,2773448,CDM,272,RC,,,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE SPECIALTY LVL 05,2773448,CDM,272,RC,,,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,1474.53,,,percent of total billed charges,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 01,2773455,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 01,2773455,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 02,2773463,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 02,2773463,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 03,2773471,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 03,2773471,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
OBTURATOR DISPOSABLE LVL 01,2773505,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
OBTURATOR DISPOSABLE LVL 01,2773505,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 01,2773513,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 01,2773513,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 02,2773521,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 02,2773521,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY OSTOMY LVL 02,2773570,CDM,271,RC,,,,,,,,inpatient,facility,,,134,56.28,113.9,128.64,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.58,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY OSTOMY LVL 02,2773570,CDM,271,RC,,,,,,,,outpatient,facility,,,134,56.28,36.18,134,,113.9,,,percent of total billed charges,,,36.18,,,percent of total billed charges,,,92.19,,,percent of total billed charges,,,90.18,,,percent of total billed charges,,,113.23,,,percent of total billed charges,,,,,,,,,116.58,,,percent of total billed charges,,,116.58,,,percent of total billed charges,,,113.9,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,134,,,fee schedule,,,134,,,fee schedule,,,134,,,fee schedule,,,,,,,,,104.65,,,percent of total billed charges,,,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY OSTOMY LVL 03,2773588,CDM,271,RC,,,,,,,,inpatient,facility,,,359,150.78,305.15,344.64,,305.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.33,,,percent of total billed charges,,,,,,,,,323.1,,,percent of total billed charges,,,344.64,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,333.87,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY OSTOMY LVL 03,2773588,CDM,271,RC,,,,,,,,outpatient,facility,,,359,150.78,96.93,359,,305.15,,,percent of total billed charges,,,96.93,,,percent of total billed charges,,,246.99,,,percent of total billed charges,,,241.61,,,percent of total billed charges,,,303.36,,,percent of total billed charges,,,,,,,,,312.33,,,percent of total billed charges,,,312.33,,,percent of total billed charges,,,305.15,,,percent of total billed charges,,,344.64,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,323.1,,,percent of total billed charges,,,,,,,,,333.87,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,359,,,fee schedule,,,359,,,fee schedule,,,359,,,fee schedule,,,,,,,,,280.38,,,percent of total billed charges,,,326.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY OSTOMY LVL 04,2773596,CDM,271,RC,,,,,,,,inpatient,facility,,,709,297.78,602.65,680.64,,602.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.83,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY OSTOMY LVL 04,2773596,CDM,271,RC,,,,,,,,outpatient,facility,,,709,297.78,191.43,709,,602.65,,,percent of total billed charges,,,191.43,,,percent of total billed charges,,,487.79,,,percent of total billed charges,,,477.16,,,percent of total billed charges,,,599.11,,,percent of total billed charges,,,,,,,,,616.83,,,percent of total billed charges,,,616.83,,,percent of total billed charges,,,602.65,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,709,,,fee schedule,,,709,,,fee schedule,,,709,,,fee schedule,,,,,,,,,553.73,,,percent of total billed charges,,,645.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PACER ACCESSORY LVL 01,2773604,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PACER ACCESSORY LVL 01,2773604,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 04,2773612,CDM,272,RC,,,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 04,2773612,CDM,272,RC,,,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL NON RR LVL 03,2773620,CDM,275,RC,C2619,HCPCS,,,,,,inpatient,facility,,,28474,11959.08,24202.9,27335.04,,24202.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24772.38,,,percent of total billed charges,,,,,,,,,25626.6,,,percent of total billed charges,,,27335.04,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26480.82,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL NON RR LVL 03,2773620,CDM,275,RC,C2619,HCPCS,,,,,,outpatient,facility,,,28474,11959.08,7687.98,28474,,24202.9,,,percent of total billed charges,,,7687.98,,,percent of total billed charges,,,19590.11,,,percent of total billed charges,,,19163,,,percent of total billed charges,,,24060.53,,,percent of total billed charges,,,,,,,,,24772.38,,,percent of total billed charges,,,24772.38,,,percent of total billed charges,,,24202.9,,,percent of total billed charges,,,27335.04,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,25626.6,,,percent of total billed charges,,,,,,,,,26480.82,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,,,,,,,28474,,,fee schedule,,,28474,,,fee schedule,,,28474,,,fee schedule,,,,,,,,,22238.19,,,percent of total billed charges,,Paid in addition to outpatient services ,25911.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL RR LVL 02,2773638,CDM,275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL RR LVL 02,2773638,CDM,275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR NONSGL OR DUAL LVL 05,2773646,CDM,275,RC,C2621,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR NONSGL OR DUAL LVL 05,2773646,CDM,275,RC,C2621,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,Paid in addition to outpatient services ,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR SGL NON RR LVL 04,2773653,CDM,275,RC,C2620,HCPCS,,,,,,inpatient,facility,,,28474,11959.08,24202.9,27335.04,,24202.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24772.38,,,percent of total billed charges,,,,,,,,,25626.6,,,percent of total billed charges,,,27335.04,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26480.82,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR SGL NON RR LVL 04,2773653,CDM,275,RC,C2620,HCPCS,,,,,,outpatient,facility,,,28474,11959.08,7687.98,28474,,24202.9,,,percent of total billed charges,,,7687.98,,,percent of total billed charges,,,19590.11,,,percent of total billed charges,,,19163,,,percent of total billed charges,,,24060.53,,,percent of total billed charges,,,,,,,,,24772.38,,,percent of total billed charges,,,24772.38,,,percent of total billed charges,,,24202.9,,,percent of total billed charges,,,27335.04,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,25626.6,,,percent of total billed charges,,,,,,,,,26480.82,,,percent of total billed charges,,,27050.3,,,percent of total billed charges,,,,,,,,,,,,,,,28474,,,fee schedule,,,28474,,,fee schedule,,,28474,,,fee schedule,,,,,,,,,22238.19,,,percent of total billed charges,,Paid in addition to outpatient services ,25911.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR SGL RR LVL 03,2773661,CDM,275,RC,C1786,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR SGL RR LVL 03,2773661,CDM,275,RC,C1786,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH WIRE SUTURE PASSER LVL 01,2773679,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH WIRE SUTURE PASSER LVL 01,2773679,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 01,2773687,CDM,272,RC,,,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 01,2773687,CDM,272,RC,,,,,,,,outpatient,facility,,,102,42.84,27.54,102,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,102,,,fee schedule,,,102,,,fee schedule,,,102,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 02,2773695,CDM,272,RC,,,,,,,,inpatient,facility,,,221,92.82,187.85,212.16,,187.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.27,,,percent of total billed charges,,,,,,,,,198.9,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 02,2773695,CDM,272,RC,,,,,,,,outpatient,facility,,,221,92.82,59.67,221,,187.85,,,percent of total billed charges,,,59.67,,,percent of total billed charges,,,152.05,,,percent of total billed charges,,,148.73,,,percent of total billed charges,,,186.75,,,percent of total billed charges,,,,,,,,,192.27,,,percent of total billed charges,,,192.27,,,percent of total billed charges,,,187.85,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,198.9,,,percent of total billed charges,,,,,,,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,221,,,fee schedule,,,221,,,fee schedule,,,221,,,fee schedule,,,,,,,,,172.6,,,percent of total billed charges,,,201.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 03,2773703,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 03,2773703,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 04,2773711,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 04,2773711,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 05,2773729,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 05,2773729,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PIN WIRE LVL 01,2773737,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PIN WIRE LVL 01,2773737,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PIN WIRE LVL 02,2773745,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PIN WIRE LVL 02,2773745,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PIN WIRE LVL 03,2773752,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PIN WIRE LVL 03,2773752,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 05,2773760,CDM,272,RC,,,,,,,,inpatient,facility,,,5861,2461.62,4981.85,5626.56,,4981.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5099.07,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 05,2773760,CDM,272,RC,,,,,,,,outpatient,facility,,,5861,2461.62,1582.47,5861,,4981.85,,,percent of total billed charges,,,1582.47,,,percent of total billed charges,,,4032.37,,,percent of total billed charges,,,3944.45,,,percent of total billed charges,,,4952.55,,,percent of total billed charges,,,,,,,,,5099.07,,,percent of total billed charges,,,5099.07,,,percent of total billed charges,,,4981.85,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,5861,,,fee schedule,,,5861,,,fee schedule,,,5861,,,fee schedule,,,,,,,,,4577.44,,,percent of total billed charges,,,5333.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 02,2773778,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 02,2773778,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 01,2773786,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 01,2773786,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 02,2773794,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 02,2773794,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 03,2773802,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 03,2773802,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 04,2773810,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 04,2773810,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 09,2773828,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6105,2564.1,5189.25,5860.8,,5189.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5311.35,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 09,2773828,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6105,2564.1,1648.35,6105,,5189.25,,,percent of total billed charges,,,1648.35,,,percent of total billed charges,,,4200.24,,,percent of total billed charges,,,4108.66,,,percent of total billed charges,,,5158.72,,,percent of total billed charges,,,,,,,,,5311.35,,,percent of total billed charges,,,5311.35,,,percent of total billed charges,,,5189.25,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,6105,,,fee schedule,,,6105,,,fee schedule,,,6105,,,fee schedule,,,,,,,,,4768,,,percent of total billed charges,,Paid in addition to outpatient services ,5555.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 05,2773836,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 05,2773836,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 06,2773844,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 06,2773844,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 07,2773851,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 07,2773851,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 08,2773869,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 08,2773869,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 10,2773877,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PLATE LVL 10,2773877,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 01,2773885,CDM,278,RC,C1788,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 01,2773885,CDM,278,RC,C1788,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROBE LVL 01,2773893,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROBE LVL 01,2773893,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROBE LVL 02,2773901,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROBE LVL 02,2773901,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROBE LVL 03,2773919,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROBE LVL 03,2773919,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 03,2773927,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 03,2773927,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROGRAMMER PT NEUROSTIM LVL 01,2773935,CDM,278,RC,C1787,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROGRAMMER PT NEUROSTIM LVL 01,2773935,CDM,278,RC,C1787,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 01,2773943,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 01,2773943,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 02,2773950,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 02,2773950,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 03,2773968,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 03,2773968,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 04,2773976,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 04,2773976,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 04,2773984,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 04,2773984,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 05,2773992,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ANKLE LVL 05,2773992,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 05,2774008,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 05,2774008,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER SUTURE LVL 02,2774016,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER SUTURE LVL 02,2774016,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP RING CARDIAC LVL 01,2774024,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP RING CARDIAC LVL 01,2774024,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP RING CARDIAC LVL 02,2774032,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP RING CARDIAC LVL 02,2774032,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 07,2774040,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6487,2724.54,5513.95,6227.52,,5513.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5643.69,,,percent of total billed charges,,,,,,,,,5838.3,,,percent of total billed charges,,,6227.52,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6032.91,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 07,2774040,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6487,2724.54,1751.49,6487,,5513.95,,,percent of total billed charges,,,1751.49,,,percent of total billed charges,,,4463.06,,,percent of total billed charges,,,4365.75,,,percent of total billed charges,,,5481.51,,,percent of total billed charges,,,,,,,,,5643.69,,,percent of total billed charges,,,5643.69,,,percent of total billed charges,,,5513.95,,,percent of total billed charges,,,6227.52,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,5838.3,,,percent of total billed charges,,,,,,,,,6032.91,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,6487,,,fee schedule,,,6487,,,fee schedule,,,6487,,,fee schedule,,,,,,,,,5066.35,,,percent of total billed charges,,Paid in addition to outpatient services ,5903.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 04,2774057,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 04,2774057,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 01,2774099,CDM,278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 01,2774099,CDM,278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 02,2774107,CDM,278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 02,2774107,CDM,278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 03,2774115,CDM,278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 03,2774115,CDM,278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 01,2774123,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 01,2774123,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 02,2774131,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 02,2774131,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 03,2774149,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 03,2774149,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 04,2774156,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 04,2774156,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 05,2774164,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 05,2774164,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV COCHLEAR INT ANDEXT CMP LVL 05,2774172,CDM,278,RC,L8614,HCPCS,,,,,,inpatient,facility,,,109504,45991.68,93078.4,105123.84,,93078.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95268.48,,,percent of total billed charges,,,,,,,,,98553.6,,,percent of total billed charges,,,105123.84,,,percent of total billed charges,,,104028.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101838.72,,,percent of total billed charges,,,104028.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV COCHLEAR INT ANDEXT CMP LVL 05,2774172,CDM,278,RC,L8614,HCPCS,,,,,,outpatient,facility,,,109504,45991.68,29566.08,109504,,93078.4,,,percent of total billed charges,,,29566.08,,,percent of total billed charges,,,75338.75,,,percent of total billed charges,,,73696.19,,,percent of total billed charges,,,92530.88,,,percent of total billed charges,,,,,,,,,95268.48,,,percent of total billed charges,,,95268.48,,,percent of total billed charges,,,93078.4,,,percent of total billed charges,,,105123.84,,,percent of total billed charges,,,104028.8,,,percent of total billed charges,,,,,,,,,98553.6,,,percent of total billed charges,,,,,,,,,101838.72,,,percent of total billed charges,,,104028.8,,,percent of total billed charges,,,,,,,,,,,,,,,109504,,,fee schedule,,,109504,,,fee schedule,,,109504,,,fee schedule,,,,,,,,,85522.62,,,percent of total billed charges,,Paid in addition to outpatient services ,99648.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 01,2774180,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 01,2774180,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 02,2774198,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 02,2774198,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 03,2774206,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 03,2774206,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 04,2774214,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 04,2774214,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 05,2774230,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT ELBOW TOTAL LVL 05,2774230,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 06,2774248,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 06,2774248,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 07,2774255,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,6487,2724.54,5513.95,6227.52,,5513.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5643.69,,,percent of total billed charges,,,,,,,,,5838.3,,,percent of total billed charges,,,6227.52,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6032.91,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 07,2774255,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,6487,2724.54,1751.49,6487,,5513.95,,,percent of total billed charges,,,1751.49,,,percent of total billed charges,,,4463.06,,,percent of total billed charges,,,4365.75,,,percent of total billed charges,,,5481.51,,,percent of total billed charges,,,,,,,,,5643.69,,,percent of total billed charges,,,5643.69,,,percent of total billed charges,,,5513.95,,,percent of total billed charges,,,6227.52,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,5838.3,,,percent of total billed charges,,,,,,,,,6032.91,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,6487,,,fee schedule,,,6487,,,fee schedule,,,6487,,,fee schedule,,,,,,,,,5066.35,,,percent of total billed charges,,Paid in addition to outpatient services ,5903.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 08,2774263,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 08,2774263,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 09,2774271,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 09,2774271,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 07,2774289,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 07,2774289,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 08,2774297,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 08,2774297,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SNARE LVL 04,2774305,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SNARE LVL 04,2774305,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 02,2774313,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 02,2774313,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 03,2774321,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 03,2774321,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 01,2774339,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 01,2774339,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 02,2774347,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 02,2774347,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 03,2774354,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH ENT LVL 03,2774354,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 01,2774362,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 01,2774362,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 02,2774370,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 02,2774370,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 04,2774388,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 04,2774388,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 05,2774404,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 05,2774404,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 04,2774412,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 04,2774412,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 11,2774420,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 11,2774420,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 05,2774446,CDM,278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 05,2774446,CDM,278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 06,2774453,CDM,278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 06,2774453,CDM,278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TRANSDUCER LVL 02,2774461,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TRANSDUCER LVL 02,2774461,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TRANSDUCER LVL 03,2774479,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TRANSDUCER LVL 03,2774479,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 02,2774487,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 02,2774487,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 03,2774495,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 03,2774495,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 03,2774503,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT FINGER LVL 03,2774503,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 01,2774511,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 01,2774511,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 02,2774529,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 02,2774529,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 03,2774537,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 03,2774537,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 04,2774545,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 04,2774545,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 09,2774552,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 09,2774552,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 05,2774560,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 05,2774560,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 06,2774578,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 06,2774578,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 07,2774586,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 07,2774586,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 08,2774594,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 08,2774594,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 10,2774602,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 10,2774602,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 11,2774610,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,30664,12878.88,26064.4,29437.44,,26064.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26677.68,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 11,2774610,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,30664,12878.88,8279.28,30664,,26064.4,,,percent of total billed charges,,,8279.28,,,percent of total billed charges,,,21096.83,,,percent of total billed charges,,,20636.87,,,percent of total billed charges,,,25911.08,,,percent of total billed charges,,,,,,,,,26677.68,,,percent of total billed charges,,,26677.68,,,percent of total billed charges,,,26064.4,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,30664,,,fee schedule,,,30664,,,fee schedule,,,30664,,,fee schedule,,,,,,,,,23948.58,,,percent of total billed charges,,Paid in addition to outpatient services ,27904.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 12,2774628,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,35044,14718.48,29787.4,33642.24,,29787.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30488.28,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 12,2774628,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,35044,14718.48,9461.88,35044,,29787.4,,,percent of total billed charges,,,9461.88,,,percent of total billed charges,,,24110.27,,,percent of total billed charges,,,23584.61,,,percent of total billed charges,,,29612.18,,,percent of total billed charges,,,,,,,,,30488.28,,,percent of total billed charges,,,30488.28,,,percent of total billed charges,,,29787.4,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,35044,,,fee schedule,,,35044,,,fee schedule,,,35044,,,fee schedule,,,,,,,,,27369.36,,,percent of total billed charges,,Paid in addition to outpatient services ,31890.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 13,2774636,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 13,2774636,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,Paid in addition to outpatient services ,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 14,2774644,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,52564,22076.88,44679.4,50461.44,,44679.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45730.68,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 14,2774644,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,52564,22076.88,14192.28,52564,,44679.4,,,percent of total billed charges,,,14192.28,,,percent of total billed charges,,,36164.03,,,percent of total billed charges,,,35375.57,,,percent of total billed charges,,,44416.58,,,percent of total billed charges,,,,,,,,,45730.68,,,percent of total billed charges,,,45730.68,,,percent of total billed charges,,,44679.4,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,52564,,,fee schedule,,,52564,,,fee schedule,,,52564,,,fee schedule,,,,,,,,,41052.48,,,percent of total billed charges,,Paid in addition to outpatient services ,47833.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 04,2774651,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 04,2774651,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 15,2774669,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,65704,27595.68,55848.4,63075.84,,55848.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57162.48,,,percent of total billed charges,,,,,,,,,59133.6,,,percent of total billed charges,,,63075.84,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61104.72,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 15,2774669,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,65704,27595.68,17740.08,65704,,55848.4,,,percent of total billed charges,,,17740.08,,,percent of total billed charges,,,45204.35,,,percent of total billed charges,,,44218.79,,,percent of total billed charges,,,55519.88,,,percent of total billed charges,,,,,,,,,57162.48,,,percent of total billed charges,,,57162.48,,,percent of total billed charges,,,55848.4,,,percent of total billed charges,,,63075.84,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,59133.6,,,percent of total billed charges,,,,,,,,,61104.72,,,percent of total billed charges,,,62418.8,,,percent of total billed charges,,,,,,,,,,,,,,,65704,,,fee schedule,,,65704,,,fee schedule,,,65704,,,fee schedule,,,,,,,,,51314.82,,,percent of total billed charges,,Paid in addition to outpatient services ,59790.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 16,2774677,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,87604,36793.68,74463.4,84099.84,,74463.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76215.48,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT HIP TOTAL LVL 16,2774677,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,87604,36793.68,23653.08,87604,,74463.4,,,percent of total billed charges,,,23653.08,,,percent of total billed charges,,,60271.55,,,percent of total billed charges,,,58957.49,,,percent of total billed charges,,,74025.38,,,percent of total billed charges,,,,,,,,,76215.48,,,percent of total billed charges,,,76215.48,,,percent of total billed charges,,,74463.4,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,87604,,,fee schedule,,,87604,,,fee schedule,,,87604,,,fee schedule,,,,,,,,,68418.72,,,percent of total billed charges,,Paid in addition to outpatient services ,79719.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 04,2774685,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,991,416.22,842.35,951.36,,842.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,862.17,,,percent of total billed charges,,,,,,,,,891.9,,,percent of total billed charges,,,951.36,,,percent of total billed charges,,,941.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,921.63,,,percent of total billed charges,,,941.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 04,2774685,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,991,416.22,267.57,991,,842.35,,,percent of total billed charges,,,267.57,,,percent of total billed charges,,,681.81,,,percent of total billed charges,,,666.94,,,percent of total billed charges,,,837.39,,,percent of total billed charges,,,,,,,,,862.17,,,percent of total billed charges,,,862.17,,,percent of total billed charges,,,842.35,,,percent of total billed charges,,,951.36,,,percent of total billed charges,,,941.45,,,percent of total billed charges,,,,,,,,,891.9,,,percent of total billed charges,,,,,,,,,921.63,,,percent of total billed charges,,,941.45,,,percent of total billed charges,,,,,,,,,,,,,,,991,,,fee schedule,,,991,,,fee schedule,,,991,,,fee schedule,,,,,,,,,773.97,,,percent of total billed charges,,,901.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 04,2774693,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 04,2774693,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 05,2774701,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 05,2774701,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 15,2774719,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,56944,23916.48,48402.4,54666.24,,48402.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49541.28,,,percent of total billed charges,,,,,,,,,51249.6,,,percent of total billed charges,,,54666.24,,,percent of total billed charges,,,54096.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52957.92,,,percent of total billed charges,,,54096.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 15,2774719,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,56944,23916.48,15374.88,56944,,48402.4,,,percent of total billed charges,,,15374.88,,,percent of total billed charges,,,39177.47,,,percent of total billed charges,,,38323.31,,,percent of total billed charges,,,48117.68,,,percent of total billed charges,,,,,,,,,49541.28,,,percent of total billed charges,,,49541.28,,,percent of total billed charges,,,48402.4,,,percent of total billed charges,,,54666.24,,,percent of total billed charges,,,54096.8,,,percent of total billed charges,,,,,,,,,51249.6,,,percent of total billed charges,,,,,,,,,52957.92,,,percent of total billed charges,,,54096.8,,,percent of total billed charges,,,,,,,,,,,,,,,56944,,,fee schedule,,,56944,,,fee schedule,,,56944,,,fee schedule,,,,,,,,,44473.26,,,percent of total billed charges,,Paid in addition to outpatient services ,51819.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 04,2774727,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 04,2774727,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 05,2774735,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 05,2774735,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 06,2774743,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 06,2774743,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 07,2774750,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 07,2774750,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 12,2774768,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 12,2774768,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,Paid in addition to outpatient services ,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 08,2774776,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 08,2774776,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 09,2774784,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,30664,12878.88,26064.4,29437.44,,26064.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26677.68,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 09,2774784,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,30664,12878.88,8279.28,30664,,26064.4,,,percent of total billed charges,,,8279.28,,,percent of total billed charges,,,21096.83,,,percent of total billed charges,,,20636.87,,,percent of total billed charges,,,25911.08,,,percent of total billed charges,,,,,,,,,26677.68,,,percent of total billed charges,,,26677.68,,,percent of total billed charges,,,26064.4,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,30664,,,fee schedule,,,30664,,,fee schedule,,,30664,,,fee schedule,,,,,,,,,23948.58,,,percent of total billed charges,,Paid in addition to outpatient services ,27904.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 10,2774792,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,35044,14718.48,29787.4,33642.24,,29787.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30488.28,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 10,2774792,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,35044,14718.48,9461.88,35044,,29787.4,,,percent of total billed charges,,,9461.88,,,percent of total billed charges,,,24110.27,,,percent of total billed charges,,,23584.61,,,percent of total billed charges,,,29612.18,,,percent of total billed charges,,,,,,,,,30488.28,,,percent of total billed charges,,,30488.28,,,percent of total billed charges,,,29787.4,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,35044,,,fee schedule,,,35044,,,fee schedule,,,35044,,,fee schedule,,,,,,,,,27369.36,,,percent of total billed charges,,Paid in addition to outpatient services ,31890.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 11,2774800,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,39424,16558.08,33510.4,37847.04,,33510.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34298.88,,,percent of total billed charges,,,,,,,,,35481.6,,,percent of total billed charges,,,37847.04,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36664.32,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 11,2774800,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,39424,16558.08,10644.48,39424,,33510.4,,,percent of total billed charges,,,10644.48,,,percent of total billed charges,,,27123.71,,,percent of total billed charges,,,26532.35,,,percent of total billed charges,,,33313.28,,,percent of total billed charges,,,,,,,,,34298.88,,,percent of total billed charges,,,34298.88,,,percent of total billed charges,,,33510.4,,,percent of total billed charges,,,37847.04,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,35481.6,,,percent of total billed charges,,,,,,,,,36664.32,,,percent of total billed charges,,,37452.8,,,percent of total billed charges,,,,,,,,,,,,,,,39424,,,fee schedule,,,39424,,,fee schedule,,,39424,,,fee schedule,,,,,,,,,30790.14,,,percent of total billed charges,,Paid in addition to outpatient services ,35875.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 13,2774818,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,48184,20237.28,40956.4,46256.64,,40956.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41920.08,,,percent of total billed charges,,,,,,,,,43365.6,,,percent of total billed charges,,,46256.64,,,percent of total billed charges,,,45774.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,44811.12,,,percent of total billed charges,,,45774.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 13,2774818,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,48184,20237.28,13009.68,48184,,40956.4,,,percent of total billed charges,,,13009.68,,,percent of total billed charges,,,33150.59,,,percent of total billed charges,,,32427.83,,,percent of total billed charges,,,40715.48,,,percent of total billed charges,,,,,,,,,41920.08,,,percent of total billed charges,,,41920.08,,,percent of total billed charges,,,40956.4,,,percent of total billed charges,,,46256.64,,,percent of total billed charges,,,45774.8,,,percent of total billed charges,,,,,,,,,43365.6,,,percent of total billed charges,,,,,,,,,44811.12,,,percent of total billed charges,,,45774.8,,,percent of total billed charges,,,,,,,,,,,,,,,48184,,,fee schedule,,,48184,,,fee schedule,,,48184,,,fee schedule,,,,,,,,,37631.7,,,percent of total billed charges,,Paid in addition to outpatient services ,43847.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 14,2774826,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,52564,22076.88,44679.4,50461.44,,44679.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45730.68,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 14,2774826,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,52564,22076.88,14192.28,52564,,44679.4,,,percent of total billed charges,,,14192.28,,,percent of total billed charges,,,36164.03,,,percent of total billed charges,,,35375.57,,,percent of total billed charges,,,44416.58,,,percent of total billed charges,,,,,,,,,45730.68,,,percent of total billed charges,,,45730.68,,,percent of total billed charges,,,44679.4,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,52564,,,fee schedule,,,52564,,,fee schedule,,,52564,,,fee schedule,,,,,,,,,41052.48,,,percent of total billed charges,,Paid in addition to outpatient services ,47833.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 16,2774834,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,61324,25756.08,52125.4,58871.04,,52125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53351.88,,,percent of total billed charges,,,,,,,,,55191.6,,,percent of total billed charges,,,58871.04,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57031.32,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 16,2774834,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,61324,25756.08,16557.48,61324,,52125.4,,,percent of total billed charges,,,16557.48,,,percent of total billed charges,,,42190.91,,,percent of total billed charges,,,41271.05,,,percent of total billed charges,,,51818.78,,,percent of total billed charges,,,,,,,,,53351.88,,,percent of total billed charges,,,53351.88,,,percent of total billed charges,,,52125.4,,,percent of total billed charges,,,58871.04,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,55191.6,,,percent of total billed charges,,,,,,,,,57031.32,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,,,,,,,61324,,,fee schedule,,,61324,,,fee schedule,,,61324,,,fee schedule,,,,,,,,,47894.04,,,percent of total billed charges,,Paid in addition to outpatient services ,55804.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 17,2774842,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,70084,29435.28,59571.4,67280.64,,59571.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60973.08,,,percent of total billed charges,,,,,,,,,63075.6,,,percent of total billed charges,,,67280.64,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65178.12,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 17,2774842,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,70084,29435.28,18922.68,70084,,59571.4,,,percent of total billed charges,,,18922.68,,,percent of total billed charges,,,48217.79,,,percent of total billed charges,,,47166.53,,,percent of total billed charges,,,59220.98,,,percent of total billed charges,,,,,,,,,60973.08,,,percent of total billed charges,,,60973.08,,,percent of total billed charges,,,59571.4,,,percent of total billed charges,,,67280.64,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,63075.6,,,percent of total billed charges,,,,,,,,,65178.12,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,,,,,,,70084,,,fee schedule,,,70084,,,fee schedule,,,70084,,,fee schedule,,,,,,,,,54735.6,,,percent of total billed charges,,Paid in addition to outpatient services ,63776.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 18,2774859,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,78844,33114.48,67017.4,75690.24,,67017.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68594.28,,,percent of total billed charges,,,,,,,,,70959.6,,,percent of total billed charges,,,75690.24,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73324.92,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT KNEE TOTAL LVL 18,2774859,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,78844,33114.48,21287.88,78844,,67017.4,,,percent of total billed charges,,,21287.88,,,percent of total billed charges,,,54244.67,,,percent of total billed charges,,,53062.01,,,percent of total billed charges,,,66623.18,,,percent of total billed charges,,,,,,,,,68594.28,,,percent of total billed charges,,,68594.28,,,percent of total billed charges,,,67017.4,,,percent of total billed charges,,,75690.24,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,70959.6,,,percent of total billed charges,,,,,,,,,73324.92,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,,,,,,,78844,,,fee schedule,,,78844,,,fee schedule,,,78844,,,fee schedule,,,,,,,,,61577.16,,,percent of total billed charges,,Paid in addition to outpatient services ,71748.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 03,2774867,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 03,2774867,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 01,2774875,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 01,2774875,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 02,2774883,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 02,2774883,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 03,2774891,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 03,2774891,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 04,2774909,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 04,2774909,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 05,2774917,CDM,278,RC,C2626,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 05,2774917,CDM,278,RC,C2626,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,,,,,,,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 05,2774925,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,6105,2564.1,5189.25,5860.8,,5189.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5311.35,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH MAXILLOFACIAL LVL 05,2774925,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,6105,2564.1,1648.35,6105,,5189.25,,,percent of total billed charges,,,1648.35,,,percent of total billed charges,,,4200.24,,,percent of total billed charges,,,4108.66,,,percent of total billed charges,,,5158.72,,,percent of total billed charges,,,,,,,,,5311.35,,,percent of total billed charges,,,5311.35,,,percent of total billed charges,,,5189.25,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,6105,,,fee schedule,,,6105,,,fee schedule,,,6105,,,fee schedule,,,,,,,,,4768,,,percent of total billed charges,,Paid in addition to outpatient services ,5555.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 02,2774933,CDM,278,RC,C2626,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 02,2774933,CDM,278,RC,C2626,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 03,2774941,CDM,278,RC,C2626,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 03,2774941,CDM,278,RC,C2626,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 04,2774958,CDM,278,RC,C2626,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 04,2774958,CDM,278,RC,C2626,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,,,,,,,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 02,2774982,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 02,2774982,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 04,2774990,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 04,2774990,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 05,2775005,CDM,272,RC,,,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 05,2775005,CDM,272,RC,,,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 06,2775054,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 06,2775054,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 03,2775070,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 03,2775070,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 04,2775088,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 04,2775088,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 05,2775096,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETHRAL LVL 05,2775096,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 04,2775104,CDM,278,RC,C1789,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH BREAST LVL 04,2775104,CDM,278,RC,C1789,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROGRAMMER PT NEUROSTIM LVL 02,2775112,CDM,278,RC,C1787,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROGRAMMER PT NEUROSTIM LVL 02,2775112,CDM,278,RC,C1787,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 06,2775120,CDM,272,RC,,,,,,,,inpatient,facility,,,4397,1846.74,3737.45,4221.12,,3737.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3825.39,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LASER FIBER LVL 06,2775120,CDM,272,RC,,,,,,,,outpatient,facility,,,4397,1846.74,1187.19,4397,,3737.45,,,percent of total billed charges,,,1187.19,,,percent of total billed charges,,,3025.14,,,percent of total billed charges,,,2959.18,,,percent of total billed charges,,,3715.46,,,percent of total billed charges,,,,,,,,,3825.39,,,percent of total billed charges,,,3825.39,,,percent of total billed charges,,,3737.45,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,4397,,,fee schedule,,,4397,,,fee schedule,,,4397,,,fee schedule,,,,,,,,,3434.06,,,percent of total billed charges,,,4001.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 07,2775138,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 07,2775138,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 08,2775146,CDM,272,RC,,,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 08,2775146,CDM,272,RC,,,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.97,,,percent of total billed charges,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CEMENT ACCESSORY LVL 02,2775153,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CEMENT ACCESSORY LVL 02,2775153,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 01,2775161,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 01,2775161,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 02,2775179,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 02,2775179,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 03,2775187,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH OPHTHALMIC LVL 03,2775187,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE INFLT LVL 02,2775195,CDM,278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE INFLT LVL 02,2775195,CDM,278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE INFLT LVL 03,2775203,CDM,278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE INFLT LVL 03,2775203,CDM,278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE INFLT LVL 04,2775211,CDM,278,RC,C1813,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE INFLT LVL 04,2775211,CDM,278,RC,C1813,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 01,2775229,CDM,278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 01,2775229,CDM,278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 02,2775237,CDM,278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 02,2775237,CDM,278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 03,2775245,CDM,278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 03,2775245,CDM,278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PLASTIC SURG LVL 01,2775252,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PLASTIC SURG LVL 01,2775252,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PLASTIC SURG LVL 02,2775260,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PLASTIC SURG LVL 02,2775260,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PLASTIC SURG LVL 03,2775278,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PLASTIC SURG LVL 03,2775278,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 05,2775286,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 05,2775286,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 06,2775294,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 06,2775294,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 07,2775302,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 07,2775302,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 08,2775310,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 08,2775310,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 06,2775328,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 06,2775328,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 09,2775336,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 09,2775336,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 10,2775344,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT SHDR TOTAL LVL 10,2775344,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 06,2775351,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 06,2775351,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 02,2775369,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 02,2775369,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 03,2775377,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 03,2775377,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 04,2775385,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 04,2775385,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 05,2775393,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 05,2775393,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 06,2775401,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 06,2775401,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 07,2775419,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 07,2775419,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 08,2775427,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,15334,6440.28,13033.9,14720.64,,13033.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13340.58,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 08,2775427,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,15334,6440.28,4140.18,15334,,13033.9,,,percent of total billed charges,,,4140.18,,,percent of total billed charges,,,10549.79,,,percent of total billed charges,,,10319.78,,,percent of total billed charges,,,12957.23,,,percent of total billed charges,,,,,,,,,13340.58,,,percent of total billed charges,,,13340.58,,,percent of total billed charges,,,13033.9,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,15334,,,fee schedule,,,15334,,,fee schedule,,,15334,,,fee schedule,,,,,,,,,11975.85,,,percent of total billed charges,,Paid in addition to outpatient services ,13953.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH TESTICULAR LVL 01,2775435,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,6105,2564.1,5189.25,5860.8,,5189.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5311.35,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH TESTICULAR LVL 01,2775435,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,6105,2564.1,1648.35,6105,,5189.25,,,percent of total billed charges,,,1648.35,,,percent of total billed charges,,,4200.24,,,percent of total billed charges,,,4108.66,,,percent of total billed charges,,,5158.72,,,percent of total billed charges,,,,,,,,,5311.35,,,percent of total billed charges,,,5311.35,,,percent of total billed charges,,,5189.25,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,6105,,,fee schedule,,,6105,,,fee schedule,,,6105,,,fee schedule,,,,,,,,,4768,,,percent of total billed charges,,Paid in addition to outpatient services ,5555.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH TESTICULAR LVL 02,2775443,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH TESTICULAR LVL 02,2775443,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH TESTICULAR LVL 03,2775450,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH TESTICULAR LVL 03,2775450,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 01,2775468,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 01,2775468,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 02,2775476,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 02,2775476,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 03,2775484,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 03,2775484,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 04,2775492,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 04,2775492,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 05,2775518,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 05,2775518,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 05,2775526,CDM,272,RC,C1757,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 05,2775526,CDM,272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,,,,,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 06,2775534,CDM,272,RC,C1757,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 06,2775534,CDM,272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 07,2775542,CDM,272,RC,C1757,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 07,2775542,CDM,272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,,,,,,,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 02,2775559,CDM,272,RC,C1758,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 02,2775559,CDM,272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 03,2775567,CDM,272,RC,C1758,HCPCS,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 03,2775567,CDM,272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,,,,,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 04,2775575,CDM,272,RC,C1758,HCPCS,,,,,,inpatient,facility,,,2827,1187.34,2402.95,2713.92,,2402.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2459.49,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH URETERAL LVL 04,2775575,CDM,272,RC,C1758,HCPCS,,,,,,outpatient,facility,,,2827,1187.34,763.29,2827,,2402.95,,,percent of total billed charges,,,763.29,,,percent of total billed charges,,,1944.98,,,percent of total billed charges,,,1902.57,,,percent of total billed charges,,,2388.82,,,percent of total billed charges,,,,,,,,,2459.49,,,percent of total billed charges,,,2459.49,,,percent of total billed charges,,,2402.95,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,2827,,,fee schedule,,,2827,,,fee schedule,,,2827,,,fee schedule,,,,,,,,,,,,,,,2572.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 02,2775583,CDM,272,RC,C1757,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 02,2775583,CDM,272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 03,2775591,CDM,272,RC,C1757,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 03,2775591,CDM,272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,,,,,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 04,2775609,CDM,272,RC,C1757,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH THROMBECTOMY EMBOLECTMY LVL 04,2775609,CDM,272,RC,C1757,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,,,,,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH SPHINCTR URIN LVL 01,2775617,CDM,278,RC,C1815,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH SPHINCTR URIN LVL 01,2775617,CDM,278,RC,C1815,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG PERM LVL 01,2775641,CDM,278,RC,C1891,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG PERM LVL 01,2775641,CDM,278,RC,C1891,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 01,2775658,CDM,278,RC,C2626,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF NONPRG TMP LVL 01,2775658,CDM,278,RC,C2626,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF PRG LVL 01,2775666,CDM,278,RC,C1772,HCPCS,,,,,,inpatient,facility,,,6105,2564.1,5189.25,5860.8,,5189.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5311.35,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PUMP INF PRG LVL 01,2775666,CDM,278,RC,C1772,HCPCS,,,,,,outpatient,facility,,,6105,2564.1,1648.35,6105,,5189.25,,,percent of total billed charges,,,1648.35,,,percent of total billed charges,,,4200.24,,,percent of total billed charges,,,4108.66,,,percent of total billed charges,,,5158.72,,,percent of total billed charges,,,,,,,,,5311.35,,,percent of total billed charges,,,5311.35,,,percent of total billed charges,,,5189.25,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,6105,,,fee schedule,,,6105,,,fee schedule,,,6105,,,fee schedule,,,,,,,,,4768,,,percent of total billed charges,,Paid in addition to outpatient services ,5555.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCH LVL 01,2775674,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCH LVL 01,2775674,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REAMER LVL 03,2775682,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REAMER LVL 03,2775682,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 09,2775690,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 09,2775690,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 02,2775708,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 02,2775708,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEUROSTIM RECVR AND TRANS LVL 01,2775716,CDM,278,RC,C1816,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEUROSTIM RECVR AND TRANS LVL 01,2775716,CDM,278,RC,C1816,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CARDIAC EVENT REC LVL 04,2775724,CDM,278,RC,C1764,HCPCS,,,,,,inpatient,facility,,,24970,10487.4,21224.5,23971.2,,21224.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21723.9,,,percent of total billed charges,,,,,,,,,22473,,,percent of total billed charges,,,23971.2,,,percent of total billed charges,,,23721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23222.1,,,percent of total billed charges,,,23721.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CARDIAC EVENT REC LVL 04,2775724,CDM,278,RC,C1764,HCPCS,,,,,,outpatient,facility,,,24970,10487.4,6741.9,24970,,21224.5,,,percent of total billed charges,,,6741.9,,,percent of total billed charges,,,17179.36,,,percent of total billed charges,,,16804.81,,,percent of total billed charges,,,21099.65,,,percent of total billed charges,,,,,,,,,21723.9,,,percent of total billed charges,,,21723.9,,,percent of total billed charges,,,21224.5,,,percent of total billed charges,,,23971.2,,,percent of total billed charges,,,23721.5,,,percent of total billed charges,,,,,,,,,22473,,,percent of total billed charges,,,,,,,,,23222.1,,,percent of total billed charges,,,23721.5,,,percent of total billed charges,,,,,,,,,,,,,,,24970,,,fee schedule,,,24970,,,fee schedule,,,24970,,,fee schedule,,,,,,,,,,,,,,,22722.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 01,2775732,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR OTHER LVL 01,2775732,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR THORACIC LVL 01,2775740,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR THORACIC LVL 01,2775740,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR THORACIC REINFUSN LVL 01,2775757,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR THORACIC REINFUSN LVL 01,2775757,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 01,2775765,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 01,2775765,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 02,2775773,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRACTOR LVL 02,2775773,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DEVICE INSERT RETRIEVAL LVL 01,2775781,CDM,272,RC,C1773,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE INSERT RETRIEVAL LVL 01,2775781,CDM,272,RC,C1773,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,,,,,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 01,2775799,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER BASKET LVL 01,2775799,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER SUTURE LVL 01,2775807,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER SUTURE LVL 01,2775807,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER VASCULAR LVL 01,2775815,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER VASCULAR LVL 01,2775815,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RETRIEVER VASCULAR LVL 02,2775823,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RETRIEVER VASCULAR LVL 02,2775823,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP RING FALLOPE LVL 03,2775831,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP RING FALLOPE LVL 03,2775831,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP RING LVL 01,2775849,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP RING LVL 01,2775849,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 03,2775856,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 03,2775856,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 04,2775864,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 04,2775864,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 01,2775872,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 01,2775872,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 02,2775880,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 02,2775880,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 03,2775898,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 03,2775898,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 04,2775906,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 04,2775906,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 05,2775914,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 05,2775914,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 06,2775922,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,5373,2256.66,4567.05,5158.08,,4567.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4674.51,,,percent of total billed charges,,,,,,,,,4835.7,,,percent of total billed charges,,,5158.08,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4996.89,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ROD NAIL LVL 06,2775922,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,5373,2256.66,1450.71,5373,,4567.05,,,percent of total billed charges,,,1450.71,,,percent of total billed charges,,,3696.62,,,percent of total billed charges,,,3616.03,,,percent of total billed charges,,,4540.18,,,percent of total billed charges,,,,,,,,,4674.51,,,percent of total billed charges,,,4674.51,,,percent of total billed charges,,,4567.05,,,percent of total billed charges,,,5158.08,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,4835.7,,,percent of total billed charges,,,,,,,,,4996.89,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,,,,,,,5373,,,fee schedule,,,5373,,,fee schedule,,,5373,,,fee schedule,,,,,,,,,4196.31,,,percent of total billed charges,,Paid in addition to outpatient services ,4889.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SCALPEL HARMONIC LVL 02,2775930,CDM,272,RC,,,,,,,,inpatient,facility,,,2426,1018.92,2062.1,2328.96,,2062.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2110.62,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SCALPEL HARMONIC LVL 02,2775930,CDM,272,RC,,,,,,,,outpatient,facility,,,2426,1018.92,655.02,2426,,2062.1,,,percent of total billed charges,,,655.02,,,percent of total billed charges,,,1669.09,,,percent of total billed charges,,,1632.7,,,percent of total billed charges,,,2049.97,,,percent of total billed charges,,,,,,,,,2110.62,,,percent of total billed charges,,,2110.62,,,percent of total billed charges,,,2062.1,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,2426,,,fee schedule,,,2426,,,fee schedule,,,2426,,,fee schedule,,,,,,,,,1894.71,,,percent of total billed charges,,,2207.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 01,2775948,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 01,2775948,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 02,2775955,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 02,2775955,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 03,2775963,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SCISSORS LVL 03,2775963,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 05,2776094,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 05,2776094,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 06,2776102,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 06,2776102,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 07,2776110,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 07,2776110,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SEAL PROXIMAL SYS LVL 01,2776136,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SEAL PROXIMAL SYS LVL 01,2776136,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SEALANT PULMONARY LIQUID LVL 01,2776144,CDM,278,RC,C2615,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SEALANT PULMONARY LIQUID LVL 01,2776144,CDM,278,RC,C2615,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SEPTAL DEFECT INTRACARD LVL 01,2776151,CDM,278,RC,C1817,HCPCS,,,,,,inpatient,facility,,,15334,6440.28,13033.9,14720.64,,13033.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13340.58,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SEPTAL DEFECT INTRACARD LVL 01,2776151,CDM,278,RC,C1817,HCPCS,,,,,,outpatient,facility,,,15334,6440.28,4140.18,15334,,13033.9,,,percent of total billed charges,,,4140.18,,,percent of total billed charges,,,10549.79,,,percent of total billed charges,,,10319.78,,,percent of total billed charges,,,12957.23,,,percent of total billed charges,,,,,,,,,13340.58,,,percent of total billed charges,,,13340.58,,,percent of total billed charges,,,13033.9,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,15334,,,fee schedule,,,15334,,,fee schedule,,,15334,,,fee schedule,,,,,,,,,,,,,,,13953.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 01,2776169,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 01,2776169,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 02,2776177,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 02,2776177,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 03,2776185,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 03,2776185,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 04,2776193,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 04,2776193,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 05,2776201,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP SHUNT LVL 05,2776201,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SLEEVE SCD LVL 01,2776250,CDM,271,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE SCD LVL 01,2776250,CDM,271,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SLEEVE SCD LVL 02,2776268,CDM,271,RC,,,,,,,,inpatient,facility,,,535,224.7,454.75,513.6,,454.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.45,,,percent of total billed charges,,,,,,,,,481.5,,,percent of total billed charges,,,513.6,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,497.55,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE SCD LVL 02,2776268,CDM,271,RC,,,,,,,,outpatient,facility,,,535,224.7,144.45,535,,454.75,,,percent of total billed charges,,,144.45,,,percent of total billed charges,,,368.08,,,percent of total billed charges,,,360.05,,,percent of total billed charges,,,452.07,,,percent of total billed charges,,,,,,,,,465.45,,,percent of total billed charges,,,465.45,,,percent of total billed charges,,,454.75,,,percent of total billed charges,,,513.6,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,481.5,,,percent of total billed charges,,,,,,,,,497.55,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,,,,,,,535,,,fee schedule,,,535,,,fee schedule,,,535,,,fee schedule,,,,,,,,,417.83,,,percent of total billed charges,,,486.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SLEEVE SCD LVL 03,2776276,CDM,271,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SLEEVE SCD LVL 03,2776276,CDM,271,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 08,2776284,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 08,2776284,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 02,2776292,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 02,2776292,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SNARE LVL 01,2776300,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SNARE LVL 01,2776300,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SNARE LVL 02,2776318,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SNARE LVL 02,2776318,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SNARE LVL 03,2776326,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SNARE LVL 03,2776326,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 01,2776334,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP EMBOLIZATION SPHERE LVL 01,2776334,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 01,2776342,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 01,2776342,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 02,2776359,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 02,2776359,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 03,2776367,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,709,297.78,602.65,680.64,,602.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.83,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STAPLE BONE LVL 03,2776367,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,709,297.78,191.43,709,,602.65,,,percent of total billed charges,,,191.43,,,percent of total billed charges,,,487.79,,,percent of total billed charges,,,477.16,,,percent of total billed charges,,,599.11,,,percent of total billed charges,,,,,,,,,616.83,,,percent of total billed charges,,,616.83,,,percent of total billed charges,,,602.65,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,709,,,fee schedule,,,709,,,fee schedule,,,709,,,fee schedule,,,,,,,,,553.73,,,percent of total billed charges,,,645.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 01,2776375,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 01,2776375,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 02,2776383,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 02,2776383,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 03,2776391,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLE RELOAD LVL 03,2776391,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 01,2776409,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 01,2776409,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 02,2776417,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 02,2776417,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 03,2776425,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 03,2776425,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 04,2776433,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 04,2776433,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 05,2776441,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STAPLER LVL 05,2776441,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 01,2776458,CDM,278,RC,C1874,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT COAT W DEL LVL 01,2776458,CDM,278,RC,C1874,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 01,2776474,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 01,2776474,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 02,2776482,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 02,2776482,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 03,2776490,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 03,2776490,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 04,2776508,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 04,2776508,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 03,2776516,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 03,2776516,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 05,2776524,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 05,2776524,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 06,2776532,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 06,2776532,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 07,2776540,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 07,2776540,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 08,2776557,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NOS LVL 08,2776557,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 04,2776565,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 04,2776565,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 01,2776573,CDM,278,RC,C1876,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT W DEL LVL 01,2776573,CDM,278,RC,C1876,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 01,2776581,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 01,2776581,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP W DEL LVL 01,2776599,CDM,278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP W DEL LVL 01,2776599,CDM,278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 01,2776607,CDM,278,RC,C2617,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP WO DEL LVL 01,2776607,CDM,278,RC,C2617,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STYLET LVL 01,2776623,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STYLET LVL 01,2776623,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STYLET LVL 02,2776631,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STYLET LVL 02,2776631,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STYLET LVL 03,2776649,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STYLET LVL 03,2776649,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 01,2776656,CDM,272,RC,,,,,,,,inpatient,facility,,,38,15.96,32.3,36.48,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,,,,,,,34.2,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 01,2776656,CDM,272,RC,,,,,,,,outpatient,facility,,,38,15.96,10.26,38,,32.3,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,26.14,,,percent of total billed charges,,,25.57,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,,,,,,,33.06,,,percent of total billed charges,,,33.06,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,34.2,,,percent of total billed charges,,,,,,,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,38,,,fee schedule,,,38,,,fee schedule,,,38,,,fee schedule,,,,,,,,,29.68,,,percent of total billed charges,,,34.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 02,2776664,CDM,272,RC,,,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 02,2776664,CDM,272,RC,,,,,,,,outpatient,facility,,,102,42.84,27.54,102,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,102,,,fee schedule,,,102,,,fee schedule,,,102,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 03,2776672,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 03,2776672,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 04,2776680,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 04,2776680,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 09,2776698,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 09,2776698,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 05,2776706,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 05,2776706,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 06,2776714,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 06,2776714,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 07,2776722,CDM,272,RC,,,,,,,,inpatient,facility,,,709,297.78,602.65,680.64,,602.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.83,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 07,2776722,CDM,272,RC,,,,,,,,outpatient,facility,,,709,297.78,191.43,709,,602.65,,,percent of total billed charges,,,191.43,,,percent of total billed charges,,,487.79,,,percent of total billed charges,,,477.16,,,percent of total billed charges,,,599.11,,,percent of total billed charges,,,,,,,,,616.83,,,percent of total billed charges,,,616.83,,,percent of total billed charges,,,602.65,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,709,,,fee schedule,,,709,,,fee schedule,,,709,,,fee schedule,,,,,,,,,553.73,,,percent of total billed charges,,,645.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 08,2776730,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 08,2776730,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 10,2776748,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUTURE LVL 10,2776748,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TIPS LVL 01,2776763,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TIPS LVL 01,2776763,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TIPS LVL 02,2776771,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TIPS LVL 02,2776771,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TIPS LVL 03,2776789,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TIPS LVL 03,2776789,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT HUMAN LVL 01,2776797,CDM,278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT HUMAN LVL 01,2776797,CDM,278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT HUMAN LVL 02,2776805,CDM,278,RC,C1762,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT HUMAN LVL 02,2776805,CDM,278,RC,C1762,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 05,2776813,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 05,2776813,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 06,2776821,CDM,278,RC,C1877,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOAT WO DEL LVL 06,2776821,CDM,278,RC,C1877,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 02,2776854,CDM,272,RC,C2627,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 02,2776854,CDM,272,RC,C2627,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 03,2776862,CDM,272,RC,C2627,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 03,2776862,CDM,272,RC,C2627,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 04,2776870,CDM,272,RC,C2627,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH SUPRAPUBIC CYSTOSCOPIC LVL 04,2776870,CDM,272,RC,C2627,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 01,2776888,CDM,278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 01,2776888,CDM,278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 02,2776896,CDM,278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 02,2776896,CDM,278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 03,2776904,CDM,278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 03,2776904,CDM,278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 04,2776912,CDM,278,RC,C1763,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TISSUE CONNECT NONHUMAN LVL 04,2776912,CDM,278,RC,C1763,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TRANSDUCER LVL 01,2776979,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TRANSDUCER LVL 01,2776979,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TREPHINE LVL 01,2776987,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TREPHINE LVL 01,2776987,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TREPHINE LVL 02,2776995,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TREPHINE LVL 02,2776995,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 01,2777001,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 01,2777001,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 02,2777019,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 02,2777019,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 03,2777027,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 03,2777027,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 04,2777035,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 04,2777035,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 05,2777043,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TROCAR LVL 05,2777043,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 01,2777050,CDM,272,RC,,,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE CHEST LVL 01,2777050,CDM,272,RC,,,,,,,,outpatient,facility,,,102,42.84,27.54,102,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,102,,,fee schedule,,,102,,,fee schedule,,,102,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP TUBE EAR LVL 01,2777068,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP TUBE EAR LVL 01,2777068,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE ENDOBRONCHIAL LVL 01,2777076,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE ENDOBRONCHIAL LVL 01,2777076,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 01,2777084,CDM,272,RC,,,,,,,,inpatient,facility,,,32,13.44,27.2,30.72,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.84,,,percent of total billed charges,,,,,,,,,28.8,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.76,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 01,2777084,CDM,272,RC,,,,,,,,outpatient,facility,,,32,13.44,8.64,32,,27.2,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,27.04,,,percent of total billed charges,,,,,,,,,27.84,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,28.8,,,percent of total billed charges,,,,,,,,,29.76,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,,,,,,,32,,,fee schedule,,,32,,,fee schedule,,,32,,,fee schedule,,,,,,,,,24.99,,,percent of total billed charges,,,29.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 03,2777092,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 03,2777092,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 02,2777100,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 02,2777100,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 04,2777118,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 04,2777118,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 09,2777126,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 09,2777126,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 05,2777134,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 05,2777134,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 06,2777142,CDM,272,RC,,,,,,,,inpatient,facility,,,709,297.78,602.65,680.64,,602.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,616.83,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 06,2777142,CDM,272,RC,,,,,,,,outpatient,facility,,,709,297.78,191.43,709,,602.65,,,percent of total billed charges,,,191.43,,,percent of total billed charges,,,487.79,,,percent of total billed charges,,,477.16,,,percent of total billed charges,,,599.11,,,percent of total billed charges,,,,,,,,,616.83,,,percent of total billed charges,,,616.83,,,percent of total billed charges,,,602.65,,,percent of total billed charges,,,680.64,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,638.1,,,percent of total billed charges,,,,,,,,,659.37,,,percent of total billed charges,,,673.55,,,percent of total billed charges,,,,,,,,,,,,,,,709,,,fee schedule,,,709,,,fee schedule,,,709,,,fee schedule,,,,,,,,,553.73,,,percent of total billed charges,,,645.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 07,2777159,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 07,2777159,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 08,2777167,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 08,2777167,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 10,2777175,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TUBE SPECIALTY LVL 10,2777175,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 02,2777258,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 02,2777258,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BIT LVL 04,2777266,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BIT LVL 04,2777266,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BIT LVL 05,2777274,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BIT LVL 05,2777274,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BIT LVL 06,2777282,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BIT LVL 06,2777282,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 01,2777290,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 01,2777290,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 02,2777308,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 02,2777308,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 03,2777316,CDM,272,RC,,,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 03,2777316,CDM,272,RC,,,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 04,2777324,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 04,2777324,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 09,2777332,CDM,272,RC,,,,,,,,inpatient,facility,,,4397,1846.74,3737.45,4221.12,,3737.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3825.39,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 09,2777332,CDM,272,RC,,,,,,,,outpatient,facility,,,4397,1846.74,1187.19,4397,,3737.45,,,percent of total billed charges,,,1187.19,,,percent of total billed charges,,,3025.14,,,percent of total billed charges,,,2959.18,,,percent of total billed charges,,,3715.46,,,percent of total billed charges,,,,,,,,,3825.39,,,percent of total billed charges,,,3825.39,,,percent of total billed charges,,,3737.45,,,percent of total billed charges,,,4221.12,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,3957.3,,,percent of total billed charges,,,,,,,,,4089.21,,,percent of total billed charges,,,4177.15,,,percent of total billed charges,,,,,,,,,,,,,,,4397,,,fee schedule,,,4397,,,fee schedule,,,4397,,,fee schedule,,,,,,,,,3434.06,,,percent of total billed charges,,,4001.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 05,2777340,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 05,2777340,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 06,2777357,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 06,2777357,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 08,2777365,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 08,2777365,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 10,2777373,CDM,272,RC,,,,,,,,inpatient,facility,,,5861,2461.62,4981.85,5626.56,,4981.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5099.07,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 10,2777373,CDM,272,RC,,,,,,,,outpatient,facility,,,5861,2461.62,1582.47,5861,,4981.85,,,percent of total billed charges,,,1582.47,,,percent of total billed charges,,,4032.37,,,percent of total billed charges,,,3944.45,,,percent of total billed charges,,,4952.55,,,percent of total billed charges,,,,,,,,,5099.07,,,percent of total billed charges,,,5099.07,,,percent of total billed charges,,,4981.85,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,5861,,,fee schedule,,,5861,,,fee schedule,,,5861,,,fee schedule,,,,,,,,,4577.44,,,percent of total billed charges,,,5333.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 01,2777381,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 01,2777381,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLIP APPLIER LVL 03,2777399,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLIP APPLIER LVL 03,2777399,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BAG DRAINAGE LVL 02,2777407,CDM,271,RC,,,,,,,,inpatient,facility,,,190,79.8,161.5,182.4,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.3,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BAG DRAINAGE LVL 02,2777407,CDM,271,RC,,,,,,,,outpatient,facility,,,190,79.8,51.3,190,,161.5,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,130.72,,,percent of total billed charges,,,127.87,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,,,,,,,165.3,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,190,,,fee schedule,,,190,,,fee schedule,,,190,,,fee schedule,,,,,,,,,148.39,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BAG DRAINAGE LVL 03,2777415,CDM,271,RC,,,,,,,,inpatient,facility,,,359,150.78,305.15,344.64,,305.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.33,,,percent of total billed charges,,,,,,,,,323.1,,,percent of total billed charges,,,344.64,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,333.87,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BAG DRAINAGE LVL 03,2777415,CDM,271,RC,,,,,,,,outpatient,facility,,,359,150.78,96.93,359,,305.15,,,percent of total billed charges,,,96.93,,,percent of total billed charges,,,246.99,,,percent of total billed charges,,,241.61,,,percent of total billed charges,,,303.36,,,percent of total billed charges,,,,,,,,,312.33,,,percent of total billed charges,,,312.33,,,percent of total billed charges,,,305.15,,,percent of total billed charges,,,344.64,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,323.1,,,percent of total billed charges,,,,,,,,,333.87,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,359,,,fee schedule,,,359,,,fee schedule,,,359,,,fee schedule,,,,,,,,,280.38,,,percent of total billed charges,,,326.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 01,2777423,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 01,2777423,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 03,2777431,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 03,2777431,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BIT LVL 01,2777449,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BIT LVL 01,2777449,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BIT LVL 02,2777456,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BIT LVL 02,2777456,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BAG DRAINAGE LVL 01,2777464,CDM,271,RC,,,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BAG DRAINAGE LVL 01,2777464,CDM,271,RC,,,,,,,,outpatient,facility,,,102,42.84,27.54,102,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,102,,,fee schedule,,,102,,,fee schedule,,,102,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GLANDULAR LVL 01,2777621,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GLANDULAR LVL 01,2777621,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 01,2777639,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRAUTERN HYST LVL 01,2777639,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RESERVOIR NEURO LVL 01,2777647,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RESERVOIR NEURO LVL 01,2777647,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 01,2777654,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 01,2777654,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSERTS LVL 01,2777662,CDM,272,RC,,,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSERTS LVL 01,2777662,CDM,272,RC,,,,,,,,outpatient,facility,,,166,69.72,44.82,166,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,,,,,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,166,,,fee schedule,,,166,,,fee schedule,,,166,,,fee schedule,,,,,,,,,129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 01,2777670,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 01,2777670,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 01,2777688,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 01,2777688,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 01,2777696,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 01,2777696,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TAPS LVL 01,2777738,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TAPS LVL 01,2777738,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL LASER LVL 07,2777803,CDM,272,RC,C1885,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ANGIO TRANSL LASER LVL 07,2777803,CDM,272,RC,C1885,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,,,,,,,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 02,2777886,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 02,2777886,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 03,2777894,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 03,2777894,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 11,2777944,CDM,272,RC,,,,,,,,inpatient,facility,,,7413,3113.46,6301.05,7116.48,,6301.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6449.31,,,percent of total billed charges,,,,,,,,,6671.7,,,percent of total billed charges,,,7116.48,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6894.09,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 11,2777944,CDM,272,RC,,,,,,,,outpatient,facility,,,7413,3113.46,2001.51,7413,,6301.05,,,percent of total billed charges,,,2001.51,,,percent of total billed charges,,,5100.14,,,percent of total billed charges,,,4988.95,,,percent of total billed charges,,,6263.98,,,percent of total billed charges,,,,,,,,,6449.31,,,percent of total billed charges,,,6449.31,,,percent of total billed charges,,,6301.05,,,percent of total billed charges,,,7116.48,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,6671.7,,,percent of total billed charges,,,,,,,,,6894.09,,,percent of total billed charges,,,7042.35,,,percent of total billed charges,,,,,,,,,,,,,,,7413,,,fee schedule,,,7413,,,fee schedule,,,7413,,,fee schedule,,,,,,,,,5789.55,,,percent of total billed charges,,,6745.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 04,2777951,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MASK AIRWAY LARYNGEAL LVL 04,2777951,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BLADE LVL 12,2777969,CDM,272,RC,,,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BLADE LVL 12,2777969,CDM,272,RC,,,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.97,,,percent of total billed charges,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 04,2777977,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 04,2777977,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 05,2777985,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 05,2777985,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 06,2777993,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP BAND LVL 06,2777993,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HYPO HYPER THERMAL LVL 02,2778009,CDM,271,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HYPO HYPER THERMAL LVL 02,2778009,CDM,271,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ERCP LVL 01,2778017,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ERCP LVL 01,2778017,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CEMENT ACCESSORIES LVL 02,2778025,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT ACCESSORIES LVL 02,2778025,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 04,2778033,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 04,2778033,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLIP LVL 02,2778041,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLIP LVL 02,2778041,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 02,2778058,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 02,2778058,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 03,2778066,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 03,2778066,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 04,2778074,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 04,2778074,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 05,2778082,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 05,2778082,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 06,2778090,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 06,2778090,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 07,2778108,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 07,2778108,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 08,2778116,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 08,2778116,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 09,2778124,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 09,2778124,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 02,2778132,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 02,2778132,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 03,2778140,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 03,2778140,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 02,2778157,CDM,272,RC,,,,,,,,inpatient,facility,,,476,199.92,404.6,456.96,,404.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.12,,,percent of total billed charges,,,,,,,,,428.4,,,percent of total billed charges,,,456.96,,,percent of total billed charges,,,452.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,442.68,,,percent of total billed charges,,,452.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 02,2778157,CDM,272,RC,,,,,,,,outpatient,facility,,,476,199.92,128.52,476,,404.6,,,percent of total billed charges,,,128.52,,,percent of total billed charges,,,327.49,,,percent of total billed charges,,,320.35,,,percent of total billed charges,,,402.22,,,percent of total billed charges,,,,,,,,,414.12,,,percent of total billed charges,,,414.12,,,percent of total billed charges,,,404.6,,,percent of total billed charges,,,456.96,,,percent of total billed charges,,,452.2,,,percent of total billed charges,,,,,,,,,428.4,,,percent of total billed charges,,,,,,,,,442.68,,,percent of total billed charges,,,452.2,,,percent of total billed charges,,,,,,,,,,,,,,,476,,,fee schedule,,,476,,,fee schedule,,,476,,,fee schedule,,,,,,,,,371.76,,,percent of total billed charges,,,433.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 03,2778165,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 03,2778165,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 04,2778173,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN W ACCESSORIES LVL 04,2778173,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FILTER VENA CAVA LVL 04,2778181,CDM,278,RC,C1880,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FILTER VENA CAVA LVL 04,2778181,CDM,278,RC,C1880,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FILTER VENA CAVA LVL 05,2778199,CDM,278,RC,C1880,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FILTER VENA CAVA LVL 05,2778199,CDM,278,RC,C1880,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 03,2778207,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 03,2778207,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 04,2778215,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 04,2778215,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 05,2778223,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 05,2778223,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 06,2778231,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FORCEP LVL 06,2778231,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 11,2778249,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 11,2778249,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,Paid in addition to outpatient services ,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 12,2778256,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 12,2778256,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 13,2778264,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,32854,13798.68,27925.9,31539.84,,27925.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28582.98,,,percent of total billed charges,,,,,,,,,29568.6,,,percent of total billed charges,,,31539.84,,,percent of total billed charges,,,31211.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30554.22,,,percent of total billed charges,,,31211.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 13,2778264,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,32854,13798.68,8870.58,32854,,27925.9,,,percent of total billed charges,,,8870.58,,,percent of total billed charges,,,22603.55,,,percent of total billed charges,,,22110.74,,,percent of total billed charges,,,27761.63,,,percent of total billed charges,,,,,,,,,28582.98,,,percent of total billed charges,,,28582.98,,,percent of total billed charges,,,27925.9,,,percent of total billed charges,,,31539.84,,,percent of total billed charges,,,31211.3,,,percent of total billed charges,,,,,,,,,29568.6,,,percent of total billed charges,,,,,,,,,30554.22,,,percent of total billed charges,,,31211.3,,,percent of total billed charges,,,,,,,,,,,,,,,32854,,,fee schedule,,,32854,,,fee schedule,,,32854,,,fee schedule,,,,,,,,,25658.97,,,percent of total billed charges,,Paid in addition to outpatient services ,29897.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 14,2778272,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 14,2778272,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,Paid in addition to outpatient services ,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 04,2778280,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 04,2778280,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 05,2778298,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 05,2778298,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,,,,,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 06,2778306,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 06,2778306,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER DUAL LVL 03,2778314,CDM,275,RC,C1721,HCPCS,,,,,,inpatient,facility,,,87604,36793.68,74463.4,84099.84,,74463.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76215.48,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER DUAL LVL 03,2778314,CDM,275,RC,C1721,HCPCS,,,,,,outpatient,facility,,,87604,36793.68,23653.08,87604,,74463.4,,,percent of total billed charges,,,23653.08,,,percent of total billed charges,,,60271.55,,,percent of total billed charges,,,58957.49,,,percent of total billed charges,,,74025.38,,,percent of total billed charges,,,,,,,,,76215.48,,,percent of total billed charges,,,76215.48,,,percent of total billed charges,,,74463.4,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,87604,,,fee schedule,,,87604,,,fee schedule,,,87604,,,fee schedule,,,,,,,,,68418.72,,,percent of total billed charges,,Paid in addition to outpatient services ,79719.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER SGL LVL 03,2778322,CDM,275,RC,C1722,HCPCS,,,,,,inpatient,facility,,,87604,36793.68,74463.4,84099.84,,74463.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76215.48,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ICD CHAMBER SGL LVL 03,2778322,CDM,275,RC,C1722,HCPCS,,,,,,outpatient,facility,,,87604,36793.68,23653.08,87604,,74463.4,,,percent of total billed charges,,,23653.08,,,percent of total billed charges,,,60271.55,,,percent of total billed charges,,,58957.49,,,percent of total billed charges,,,74025.38,,,percent of total billed charges,,,,,,,,,76215.48,,,percent of total billed charges,,,76215.48,,,percent of total billed charges,,,74463.4,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,87604,,,fee schedule,,,87604,,,fee schedule,,,87604,,,fee schedule,,,,,,,,,68418.72,,,percent of total billed charges,,Paid in addition to outpatient services ,79719.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSERTS LVL 02,2778330,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSERTS LVL 02,2778330,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 06,2778348,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP SINGLE LVL 06,2778348,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 06,2778355,CDM,272,RC,,,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 06,2778355,CDM,272,RC,,,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 07,2778363,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 07,2778363,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 04,2778371,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 04,2778371,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 05,2778389,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IRRIGATOR ACCESSORY LVL 05,2778389,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 02,2778397,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 02,2778397,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 03,2778405,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 03,2778405,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 04,2778413,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 04,2778413,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 05,2778421,CDM,272,RC,,,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 05,2778421,CDM,272,RC,,,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 06,2778439,CDM,272,RC,,,,,,,,inpatient,facility,,,5373,2256.66,4567.05,5158.08,,4567.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4674.51,,,percent of total billed charges,,,,,,,,,4835.7,,,percent of total billed charges,,,5158.08,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4996.89,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE CARDIAC LVL 06,2778439,CDM,272,RC,,,,,,,,outpatient,facility,,,5373,2256.66,1450.71,5373,,4567.05,,,percent of total billed charges,,,1450.71,,,percent of total billed charges,,,3696.62,,,percent of total billed charges,,,3616.03,,,percent of total billed charges,,,4540.18,,,percent of total billed charges,,,,,,,,,4674.51,,,percent of total billed charges,,,4674.51,,,percent of total billed charges,,,4567.05,,,percent of total billed charges,,,5158.08,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,4835.7,,,percent of total billed charges,,,,,,,,,4996.89,,,percent of total billed charges,,,5104.35,,,percent of total billed charges,,,,,,,,,,,,,,,5373,,,fee schedule,,,5373,,,fee schedule,,,5373,,,fee schedule,,,,,,,,,4196.31,,,percent of total billed charges,,,4889.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KNOT PUSHER LVL 02,2778447,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KNOT PUSHER LVL 02,2778447,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KNOT PUSHER LVL 03,2778454,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KNOT PUSHER LVL 03,2778454,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TIPS LVL 04,2778462,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TIPS LVL 04,2778462,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP MARKER TISSUE LVL 02,2778470,CDM,278,RC,A4648,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP MARKER TISSUE LVL 02,2778470,CDM,278,RC,A4648,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 04,2778488,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 04,2778488,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 05,2778496,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 05,2778496,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 06,2778504,CDM,272,RC,,,,,,,,inpatient,facility,,,5861,2461.62,4981.85,5626.56,,4981.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5099.07,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NEEDLE BIOPSY LVL 06,2778504,CDM,272,RC,,,,,,,,outpatient,facility,,,5861,2461.62,1582.47,5861,,4981.85,,,percent of total billed charges,,,1582.47,,,percent of total billed charges,,,4032.37,,,percent of total billed charges,,,3944.45,,,percent of total billed charges,,,4952.55,,,percent of total billed charges,,,,,,,,,5099.07,,,percent of total billed charges,,,5099.07,,,percent of total billed charges,,,4981.85,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,5861,,,fee schedule,,,5861,,,fee schedule,,,5861,,,fee schedule,,,,,,,,,4577.44,,,percent of total billed charges,,,5333.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CEMENT ACCESSORIES LVL 03,2778512,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CEMENT ACCESSORIES LVL 03,2778512,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 04,2778520,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 04,2778520,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 04,2778538,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 04,2778538,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 05,2778546,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CEMENT LVL 05,2778546,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 05,2778553,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 05,2778553,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
OBTURATOR DISPOSABLE LVL 02,2778561,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
OBTURATOR DISPOSABLE LVL 02,2778561,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 03,2778579,CDM,272,RC,,,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 03,2778579,CDM,272,RC,,,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10852,,,percent of total billed charges,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 04,2778587,CDM,272,RC,,,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
OCCLUDER LVL 04,2778587,CDM,272,RC,,,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 06,2778595,CDM,272,RC,,,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 06,2778595,CDM,272,RC,,,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 07,2778603,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CLAMP LVL 07,2778603,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 02,2778611,CDM,278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 02,2778611,CDM,278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 07,2778629,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 07,2778629,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 08,2778637,CDM,272,RC,C1769,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WIRE GUIDE LVL 08,2778637,CDM,272,RC,C1769,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,,,,,,,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 04,2778645,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 04,2778645,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 04,2778652,CDM,278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 04,2778652,CDM,278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,,,,,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 08,2778660,CDM,272,RC,,,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTRUMENT DISP MULTIPLE LVL 08,2778660,CDM,272,RC,,,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO LVL 04,2778678,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO LVL 04,2778678,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO LVL 05,2778686,CDM,272,RC,,,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO LVL 05,2778686,CDM,272,RC,,,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,1474.53,,,percent of total billed charges,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 03,2778694,CDM,278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 03,2778694,CDM,278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,,,,,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 02,2778702,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 02,2778702,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 03,2778710,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 03,2778710,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 04,2778728,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 04,2778728,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 05,2778736,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 05,2778736,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 06,2778744,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 06,2778744,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 07,2778751,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 07,2778751,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 08,2778769,CDM,272,RC,,,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 08,2778769,CDM,272,RC,,,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 09,2778777,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE SURG LVL 09,2778777,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 05,2778785,CDM,278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 05,2778785,CDM,278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,,,,,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 02,2778793,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 02,2778793,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 03,2778801,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 03,2778801,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 04,2778819,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 04,2778819,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 05,2778827,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 05,2778827,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 06,2778835,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 06,2778835,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 07,2778843,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 07,2778843,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 08,2778850,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 08,2778850,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 09,2778868,CDM,278,RC,C1899,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD PCMKR ICD COMBO LVL 09,2778868,CDM,278,RC,C1899,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 05,2778876,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 05,2778876,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 06,2778884,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 06,2778884,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 07,2778892,CDM,272,RC,,,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 07,2778892,CDM,272,RC,,,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.97,,,percent of total billed charges,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 08,2778900,CDM,272,RC,,,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY NEURO LVL 08,2778900,CDM,272,RC,,,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10852,,,percent of total billed charges,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRUSH LVL 03,2778918,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRUSH LVL 03,2778918,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BURR LVL 07,2778926,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BURR LVL 07,2778926,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 06,2778934,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CABLE LVL 06,2778934,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 06,2778942,CDM,278,RC,C1760,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV CLOSURE VASCULAR LVL 06,2778942,CDM,278,RC,C1760,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 10,2778959,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,15334,6440.28,13033.9,14720.64,,13033.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13340.58,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP COIL EMBOLIZATION LVL 10,2778959,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,15334,6440.28,4140.18,15334,,13033.9,,,percent of total billed charges,,,4140.18,,,percent of total billed charges,,,10549.79,,,percent of total billed charges,,,10319.78,,,percent of total billed charges,,,12957.23,,,percent of total billed charges,,,,,,,,,13340.58,,,percent of total billed charges,,,13340.58,,,percent of total billed charges,,,13033.9,,,percent of total billed charges,,,14720.64,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,13800.6,,,percent of total billed charges,,,,,,,,,14260.62,,,percent of total billed charges,,,14567.3,,,percent of total billed charges,,,,,,,,,,,,,,,15334,,,fee schedule,,,15334,,,fee schedule,,,15334,,,fee schedule,,,,,,,,,11975.85,,,percent of total billed charges,,Paid in addition to outpatient services ,13953.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
COIL IMAGING MAGNETIC RESON LVL 02,2778967,CDM,272,RC,C1770,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
COIL IMAGING MAGNETIC RESON LVL 02,2778967,CDM,272,RC,C1770,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY COLD LVL 03,2778975,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY COLD LVL 03,2778975,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ACCESS SYSTEM DIALYS LVL 02,2778983,CDM,278,RC,C1881,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ACCESS SYSTEM DIALYS LVL 02,2778983,CDM,278,RC,C1881,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP ACCESS SYSTEM DIALYS LVL 03,2778991,CDM,278,RC,C1881,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP ACCESS SYSTEM DIALYS LVL 03,2778991,CDM,278,RC,C1881,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 02,2779007,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 02,2779007,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 03,2779015,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 03,2779015,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 04,2779023,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIALYSIS ACCESSORIES LVL 04,2779023,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 04,2779031,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 04,2779031,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 05,2779049,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRAIN REINFUSION LVL 05,2779049,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 02,2779056,CDM,272,RC,C1732,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 02,2779056,CDM,272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,,,,,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 03,2779064,CDM,272,RC,C1732,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 03,2779064,CDM,272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 04,2779072,CDM,272,RC,C1732,HCPCS,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 04,2779072,CDM,272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,,,,,,,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 05,2779080,CDM,272,RC,C1732,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 05,2779080,CDM,272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,,,,,,,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 06,2779098,CDM,272,RC,C1732,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ABL EP 3D VECTOR LVL 06,2779098,CDM,272,RC,C1732,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,,,,,,,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL DIRECT LVL 02,2779106,CDM,272,RC,C1714,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL DIRECT LVL 02,2779106,CDM,272,RC,C1714,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL ROTAT LVL 02,2779114,CDM,272,RC,C1724,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ATHERECT TRANSL ROTAT LVL 02,2779114,CDM,272,RC,C1724,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 02,2779122,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 02,2779122,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 03,2779130,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 03,2779130,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 04,2779148,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 04,2779148,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 05,2779155,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 05,2779155,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 06,2779163,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 06,2779163,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 07,2779171,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON LVL 07,2779171,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 02,2779189,CDM,272,RC,C1726,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 02,2779189,CDM,272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,,,,,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 03,2779197,CDM,272,RC,C1726,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 03,2779197,CDM,272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 04,2779205,CDM,272,RC,C1726,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 04,2779205,CDM,272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,,,,,,,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 05,2779213,CDM,272,RC,C1726,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH BALLOON DILAT NONVASC LVL 05,2779213,CDM,272,RC,C1726,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH BRACHY SEED ADM LVL 06,2779239,CDM,278,RC,C1728,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH BRACHY SEED ADM LVL 06,2779239,CDM,278,RC,C1728,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,,,,,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 02,2779247,CDM,272,RC,,,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 02,2779247,CDM,272,RC,,,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 03,2779254,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 03,2779254,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 04,2779262,CDM,272,RC,,,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 04,2779262,CDM,272,RC,,,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,1474.53,,,percent of total billed charges,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 02,2779270,CDM,272,RC,,,,,,,,inpatient,facility,,,134,56.28,113.9,128.64,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.58,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 02,2779270,CDM,272,RC,,,,,,,,outpatient,facility,,,134,56.28,36.18,134,,113.9,,,percent of total billed charges,,,36.18,,,percent of total billed charges,,,92.19,,,percent of total billed charges,,,90.18,,,percent of total billed charges,,,113.23,,,percent of total billed charges,,,,,,,,,116.58,,,percent of total billed charges,,,116.58,,,percent of total billed charges,,,113.9,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,134,,,fee schedule,,,134,,,fee schedule,,,134,,,fee schedule,,,,,,,,,104.65,,,percent of total billed charges,,,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 03,2779288,CDM,272,RC,,,,,,,,inpatient,facility,,,251,105.42,213.35,240.96,,213.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.37,,,percent of total billed charges,,,,,,,,,225.9,,,percent of total billed charges,,,240.96,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,233.43,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 03,2779288,CDM,272,RC,,,,,,,,outpatient,facility,,,251,105.42,67.77,251,,213.35,,,percent of total billed charges,,,67.77,,,percent of total billed charges,,,172.69,,,percent of total billed charges,,,168.92,,,percent of total billed charges,,,212.09,,,percent of total billed charges,,,,,,,,,218.37,,,percent of total billed charges,,,218.37,,,percent of total billed charges,,,213.35,,,percent of total billed charges,,,240.96,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,225.9,,,percent of total billed charges,,,,,,,,,233.43,,,percent of total billed charges,,,238.45,,,percent of total billed charges,,,,,,,,,,,,,,,251,,,fee schedule,,,251,,,fee schedule,,,251,,,fee schedule,,,,,,,,,196.03,,,percent of total billed charges,,,228.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 04,2779296,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 04,2779296,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 05,2779304,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 05,2779304,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 06,2779312,CDM,272,RC,,,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 06,2779312,CDM,272,RC,,,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 07,2779320,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 07,2779320,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 08,2779338,CDM,272,RC,,,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 08,2779338,CDM,272,RC,,,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 09,2779346,CDM,272,RC,,,,,,,,inpatient,facility,,,5861,2461.62,4981.85,5626.56,,4981.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5099.07,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH DIAGNOSTIC LVL 09,2779346,CDM,272,RC,,,,,,,,outpatient,facility,,,5861,2461.62,1582.47,5861,,4981.85,,,percent of total billed charges,,,1582.47,,,percent of total billed charges,,,4032.37,,,percent of total billed charges,,,3944.45,,,percent of total billed charges,,,4952.55,,,percent of total billed charges,,,,,,,,,5099.07,,,percent of total billed charges,,,5099.07,,,percent of total billed charges,,,4981.85,,,percent of total billed charges,,,5626.56,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,5274.9,,,percent of total billed charges,,,,,,,,,5450.73,,,percent of total billed charges,,,5567.95,,,percent of total billed charges,,,,,,,,,,,,,,,5861,,,fee schedule,,,5861,,,fee schedule,,,5861,,,fee schedule,,,,,,,,,4577.44,,,percent of total billed charges,,,5333.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 02,2779353,CDM,272,RC,C1730,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 02,2779353,CDM,272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,,,,,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 03,2779361,CDM,272,RC,C1730,HCPCS,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 03,2779361,CDM,272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,,,,,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 04,2779379,CDM,272,RC,C1730,HCPCS,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 04,2779379,CDM,272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,,,,,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 05,2779387,CDM,272,RC,C1730,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 05,2779387,CDM,272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,,,,,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 06,2779395,CDM,272,RC,C1730,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH EP NON 3D 1 19 LVL 06,2779395,CDM,272,RC,C1730,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,,,,,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 02,2779403,CDM,272,RC,C1887,HCPCS,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 02,2779403,CDM,272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,,,,,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 03,2779411,CDM,272,RC,C1887,HCPCS,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 03,2779411,CDM,272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,,,,,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 04,2779429,CDM,272,RC,C1887,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 04,2779429,CDM,272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,,,,,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 05,2779437,CDM,272,RC,C1887,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 05,2779437,CDM,272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,,,,,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 06,2779445,CDM,272,RC,C1887,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 06,2779445,CDM,272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,,,,,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 07,2779452,CDM,272,RC,C1887,HCPCS,,,,,,inpatient,facility,,,2827,1187.34,2402.95,2713.92,,2402.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2459.49,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH GUIDE LVL 07,2779452,CDM,272,RC,C1887,HCPCS,,,,,,outpatient,facility,,,2827,1187.34,763.29,2827,,2402.95,,,percent of total billed charges,,,763.29,,,percent of total billed charges,,,1944.98,,,percent of total billed charges,,,1902.57,,,percent of total billed charges,,,2388.82,,,percent of total billed charges,,,,,,,,,2459.49,,,percent of total billed charges,,,2459.49,,,percent of total billed charges,,,2402.95,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,2827,,,fee schedule,,,2827,,,fee schedule,,,2827,,,fee schedule,,,,,,,,,,,,,,,2572.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 02,2779460,CDM,272,RC,C1752,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 02,2779460,CDM,272,RC,C1752,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 03,2779478,CDM,272,RC,C1752,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 03,2779478,CDM,272,RC,C1752,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 04,2779486,CDM,272,RC,C1752,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH HEM PER SHORT TERM LVL 04,2779486,CDM,272,RC,C1752,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 02,2779494,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 02,2779494,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 03,2779502,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,1132,475.44,962.2,1086.72,,962.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,984.84,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 03,2779502,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,1132,475.44,305.64,1132,,962.2,,,percent of total billed charges,,,305.64,,,percent of total billed charges,,,778.82,,,percent of total billed charges,,,761.84,,,percent of total billed charges,,,956.54,,,percent of total billed charges,,,,,,,,,984.84,,,percent of total billed charges,,,984.84,,,percent of total billed charges,,,962.2,,,percent of total billed charges,,,1086.72,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,1018.8,,,percent of total billed charges,,,,,,,,,1052.76,,,percent of total billed charges,,,1075.4,,,percent of total billed charges,,,,,,,,,,,,,,,1132,,,fee schedule,,,1132,,,fee schedule,,,1132,,,fee schedule,,,,,,,,,884.09,,,percent of total billed charges,,,1030.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 04,2779510,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 04,2779510,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 05,2779528,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 05,2779528,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 06,2779536,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,3596,1510.32,3056.6,3452.16,,3056.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3128.52,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 06,2779536,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,3596,1510.32,970.92,3596,,3056.6,,,percent of total billed charges,,,970.92,,,percent of total billed charges,,,2474.05,,,percent of total billed charges,,,2420.11,,,percent of total billed charges,,,3038.62,,,percent of total billed charges,,,,,,,,,3128.52,,,percent of total billed charges,,,3128.52,,,percent of total billed charges,,,3056.6,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,3236.4,,,percent of total billed charges,,,,,,,,,3344.28,,,percent of total billed charges,,,3416.2,,,percent of total billed charges,,,,,,,,,,,,,,,3596,,,fee schedule,,,3596,,,fee schedule,,,3596,,,fee schedule,,,,,,,,,2808.48,,,percent of total billed charges,,,3272.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 07,2779544,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 07,2779544,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 08,2779551,CDM,278,RC,C1750,HCPCS,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH HEM PER LONG TERM LVL 08,2779551,CDM,278,RC,C1750,HCPCS,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,Paid in addition to outpatient services ,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 07,2779569,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRESSING SPECIALTY LVL 07,2779569,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 15,2779577,CDM,278,RC,C1768,HCPCS,,,,,,inpatient,facility,,,54754,22996.68,46540.9,52563.84,,46540.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47635.98,,,percent of total billed charges,,,,,,,,,49278.6,,,percent of total billed charges,,,52563.84,,,percent of total billed charges,,,52016.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50921.22,,,percent of total billed charges,,,52016.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP GRAFT VASCULAR LVL 15,2779577,CDM,278,RC,C1768,HCPCS,,,,,,outpatient,facility,,,54754,22996.68,14783.58,54754,,46540.9,,,percent of total billed charges,,,14783.58,,,percent of total billed charges,,,37670.75,,,percent of total billed charges,,,36849.44,,,percent of total billed charges,,,46267.13,,,percent of total billed charges,,,,,,,,,47635.98,,,percent of total billed charges,,,47635.98,,,percent of total billed charges,,,46540.9,,,percent of total billed charges,,,52563.84,,,percent of total billed charges,,,52016.3,,,percent of total billed charges,,,,,,,,,49278.6,,,percent of total billed charges,,,,,,,,,50921.22,,,percent of total billed charges,,,52016.3,,,percent of total billed charges,,,,,,,,,,,,,,,54754,,,fee schedule,,,54754,,,fee schedule,,,54754,,,fee schedule,,,,,,,,,42762.87,,,percent of total billed charges,,Paid in addition to outpatient services ,49826.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 04,2779585,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 04,2779585,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 05,2779593,CDM,272,RC,,,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 05,2779593,CDM,272,RC,,,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.97,,,percent of total billed charges,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 06,2779601,CDM,272,RC,,,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HANDPIECE LVL 06,2779601,CDM,272,RC,,,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10852,,,percent of total billed charges,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HARVESTER LVL 02,2779619,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HARVESTER LVL 02,2779619,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HARVESTER LVL 03,2779627,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HARVESTER LVL 03,2779627,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 02,2779635,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 02,2779635,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 03,2779643,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 03,2779643,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 04,2779650,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 04,2779650,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 05,2779668,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 05,2779668,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 06,2779676,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 06,2779676,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 07,2779684,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP NEURO LVL 07,2779684,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,Paid in addition to outpatient services ,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 02,2779692,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 02,2779692,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 03,2779700,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 03,2779700,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 04,2779718,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 04,2779718,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 05,2779726,CDM,272,RC,,,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE GI LVL 05,2779726,CDM,272,RC,,,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.97,,,percent of total billed charges,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 02,2779734,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 02,2779734,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 03,2779742,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 03,2779742,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 04,2779759,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 04,2779759,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 05,2779767,CDM,272,RC,,,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 05,2779767,CDM,272,RC,,,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.97,,,percent of total billed charges,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 06,2779775,CDM,272,RC,,,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
KIT SET NON ROUTINE ORTH LVL 06,2779775,CDM,272,RC,,,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10852,,,percent of total billed charges,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 02,2779783,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 02,2779783,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 03,2779791,CDM,272,RC,,,,,,,,inpatient,facility,,,1126,472.92,957.1,1080.96,,957.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,979.62,,,percent of total billed charges,,,,,,,,,1013.4,,,percent of total billed charges,,,1080.96,,,percent of total billed charges,,,1069.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1047.18,,,percent of total billed charges,,,1069.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 03,2779791,CDM,272,RC,,,,,,,,outpatient,facility,,,1126,472.92,304.02,1126,,957.1,,,percent of total billed charges,,,304.02,,,percent of total billed charges,,,774.69,,,percent of total billed charges,,,757.8,,,percent of total billed charges,,,951.47,,,percent of total billed charges,,,,,,,,,979.62,,,percent of total billed charges,,,979.62,,,percent of total billed charges,,,957.1,,,percent of total billed charges,,,1080.96,,,percent of total billed charges,,,1069.7,,,percent of total billed charges,,,,,,,,,1013.4,,,percent of total billed charges,,,,,,,,,1047.18,,,percent of total billed charges,,,1069.7,,,percent of total billed charges,,,,,,,,,,,,,,,1126,,,fee schedule,,,1126,,,fee schedule,,,1126,,,fee schedule,,,,,,,,,879.41,,,percent of total billed charges,,,1024.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 04,2779809,CDM,272,RC,,,,,,,,inpatient,facility,,,1619,679.98,1376.15,1554.24,,1376.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1408.53,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MAMMOTOME LVL 04,2779809,CDM,272,RC,,,,,,,,outpatient,facility,,,1619,679.98,437.13,1619,,1376.15,,,percent of total billed charges,,,437.13,,,percent of total billed charges,,,1113.87,,,percent of total billed charges,,,1089.59,,,percent of total billed charges,,,1368.06,,,percent of total billed charges,,,,,,,,,1408.53,,,percent of total billed charges,,,1408.53,,,percent of total billed charges,,,1376.15,,,percent of total billed charges,,,1554.24,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,1457.1,,,percent of total billed charges,,,,,,,,,1505.67,,,percent of total billed charges,,,1538.05,,,percent of total billed charges,,,,,,,,,,,,,,,1619,,,fee schedule,,,1619,,,fee schedule,,,1619,,,fee schedule,,,,,,,,,1264.44,,,percent of total billed charges,,,1473.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL RR LVL 03,2779817,CDM,275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL RR LVL 03,2779817,CDM,275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL RR LVL 04,2779825,CDM,275,RC,C1785,HCPCS,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR DUAL RR LVL 04,2779825,CDM,275,RC,C1785,HCPCS,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,Paid in addition to outpatient services ,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 06,2779833,CDM,272,RC,,,,,,,,inpatient,facility,,,2426,1018.92,2062.1,2328.96,,2062.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2110.62,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 06,2779833,CDM,272,RC,,,,,,,,outpatient,facility,,,2426,1018.92,655.02,2426,,2062.1,,,percent of total billed charges,,,655.02,,,percent of total billed charges,,,1669.09,,,percent of total billed charges,,,1632.7,,,percent of total billed charges,,,2049.97,,,percent of total billed charges,,,,,,,,,2110.62,,,percent of total billed charges,,,2110.62,,,percent of total billed charges,,,2062.1,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,2426,,,fee schedule,,,2426,,,fee schedule,,,2426,,,fee schedule,,,,,,,,,1894.71,,,percent of total billed charges,,,2207.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 07,2779841,CDM,272,RC,,,,,,,,inpatient,facility,,,3340,1402.8,2839,3206.4,,2839,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2905.8,,,percent of total billed charges,,,,,,,,,3006,,,percent of total billed charges,,,3206.4,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.2,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 07,2779841,CDM,272,RC,,,,,,,,outpatient,facility,,,3340,1402.8,901.8,3340,,2839,,,percent of total billed charges,,,901.8,,,percent of total billed charges,,,2297.92,,,percent of total billed charges,,,2247.82,,,percent of total billed charges,,,2822.3,,,percent of total billed charges,,,,,,,,,2905.8,,,percent of total billed charges,,,2905.8,,,percent of total billed charges,,,2839,,,percent of total billed charges,,,3206.4,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,3006,,,percent of total billed charges,,,,,,,,,3106.2,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,,,,,,,3340,,,fee schedule,,,3340,,,fee schedule,,,3340,,,fee schedule,,,,,,,,,2608.54,,,percent of total billed charges,,,3039.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 08,2779858,CDM,272,RC,,,,,,,,inpatient,facility,,,4153,1744.26,3530.05,3986.88,,3530.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3613.11,,,percent of total billed charges,,,,,,,,,3737.7,,,percent of total billed charges,,,3986.88,,,percent of total billed charges,,,3945.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3862.29,,,percent of total billed charges,,,3945.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SUPPLY PERFUSION ECMO LVL 08,2779858,CDM,272,RC,,,,,,,,outpatient,facility,,,4153,1744.26,1121.31,4153,,3530.05,,,percent of total billed charges,,,1121.31,,,percent of total billed charges,,,2857.26,,,percent of total billed charges,,,2794.97,,,percent of total billed charges,,,3509.28,,,percent of total billed charges,,,,,,,,,3613.11,,,percent of total billed charges,,,3613.11,,,percent of total billed charges,,,3530.05,,,percent of total billed charges,,,3986.88,,,percent of total billed charges,,,3945.35,,,percent of total billed charges,,,,,,,,,3737.7,,,percent of total billed charges,,,,,,,,,3862.29,,,percent of total billed charges,,,3945.35,,,percent of total billed charges,,,,,,,,,,,,,,,4153,,,fee schedule,,,4153,,,fee schedule,,,4153,,,fee schedule,,,,,,,,,3243.49,,,percent of total billed charges,,,3779.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 02,2779866,CDM,278,RC,C1788,HCPCS,,,,,,inpatient,facility,,,447,187.74,379.95,429.12,,379.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,388.89,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 02,2779866,CDM,278,RC,C1788,HCPCS,,,,,,outpatient,facility,,,447,187.74,120.69,447,,379.95,,,percent of total billed charges,,,120.69,,,percent of total billed charges,,,307.54,,,percent of total billed charges,,,300.83,,,percent of total billed charges,,,377.71,,,percent of total billed charges,,,,,,,,,388.89,,,percent of total billed charges,,,388.89,,,percent of total billed charges,,,379.95,,,percent of total billed charges,,,429.12,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,402.3,,,percent of total billed charges,,,,,,,,,415.71,,,percent of total billed charges,,,424.65,,,percent of total billed charges,,,,,,,,,,,,,,,447,,,fee schedule,,,447,,,fee schedule,,,447,,,fee schedule,,,,,,,,,349.11,,,percent of total billed charges,,,406.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 03,2779874,CDM,278,RC,C1788,HCPCS,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 03,2779874,CDM,278,RC,C1788,HCPCS,,,,,,outpatient,facility,,,850,357,229.5,850,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,,,,,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,850,,,fee schedule,,,850,,,fee schedule,,,850,,,fee schedule,,,,,,,,,663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PCMKR SGL RR LVL 04,2779882,CDM,275,RC,C1786,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PCMKR SGL RR LVL 04,2779882,CDM,275,RC,C1786,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH WIRE SUTURE PASSER LVL 02,2779890,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH WIRE SUTURE PASSER LVL 02,2779890,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 04,2779908,CDM,278,RC,C1788,HCPCS,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 04,2779908,CDM,278,RC,C1788,HCPCS,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 05,2779916,CDM,278,RC,C1788,HCPCS,,,,,,inpatient,facility,,,1888,792.96,1604.8,1812.48,,1604.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1642.56,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 05,2779916,CDM,278,RC,C1788,HCPCS,,,,,,outpatient,facility,,,1888,792.96,509.76,1888,,1604.8,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,1298.94,,,percent of total billed charges,,,1270.62,,,percent of total billed charges,,,1595.36,,,percent of total billed charges,,,,,,,,,1642.56,,,percent of total billed charges,,,1642.56,,,percent of total billed charges,,,1604.8,,,percent of total billed charges,,,1812.48,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,1699.2,,,percent of total billed charges,,,,,,,,,1755.84,,,percent of total billed charges,,,1793.6,,,percent of total billed charges,,,,,,,,,,,,,,,1888,,,fee schedule,,,1888,,,fee schedule,,,1888,,,fee schedule,,,,,,,,,1474.53,,,percent of total billed charges,,,1718.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 06,2779924,CDM,278,RC,C1788,HCPCS,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 06,2779924,CDM,278,RC,C1788,HCPCS,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 07,2779932,CDM,278,RC,C1788,HCPCS,,,,,,inpatient,facility,,,3340,1402.8,2839,3206.4,,2839,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2905.8,,,percent of total billed charges,,,,,,,,,3006,,,percent of total billed charges,,,3206.4,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3106.2,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH PORT INDWELLING LVL 07,2779932,CDM,278,RC,C1788,HCPCS,,,,,,outpatient,facility,,,3340,1402.8,901.8,3340,,2839,,,percent of total billed charges,,,901.8,,,percent of total billed charges,,,2297.92,,,percent of total billed charges,,,2247.82,,,percent of total billed charges,,,2822.3,,,percent of total billed charges,,,,,,,,,2905.8,,,percent of total billed charges,,,2905.8,,,percent of total billed charges,,,2839,,,percent of total billed charges,,,3206.4,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,3006,,,percent of total billed charges,,,,,,,,,3106.2,,,percent of total billed charges,,,3173,,,percent of total billed charges,,,,,,,,,,,,,,,3340,,,fee schedule,,,3340,,,fee schedule,,,3340,,,fee schedule,,,,,,,,,2608.54,,,percent of total billed charges,,,3039.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROBE LVL 04,2779940,CDM,272,RC,,,,,,,,inpatient,facility,,,2157,905.94,1833.45,2070.72,,1833.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1876.59,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROBE LVL 04,2779940,CDM,272,RC,,,,,,,,outpatient,facility,,,2157,905.94,582.39,2157,,1833.45,,,percent of total billed charges,,,582.39,,,percent of total billed charges,,,1484.02,,,percent of total billed charges,,,1451.66,,,percent of total billed charges,,,1822.66,,,percent of total billed charges,,,,,,,,,1876.59,,,percent of total billed charges,,,1876.59,,,percent of total billed charges,,,1833.45,,,percent of total billed charges,,,2070.72,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,1941.3,,,percent of total billed charges,,,,,,,,,2006.01,,,percent of total billed charges,,,2049.15,,,percent of total billed charges,,,,,,,,,,,,,,,2157,,,fee schedule,,,2157,,,fee schedule,,,2157,,,fee schedule,,,,,,,,,1684.62,,,percent of total billed charges,,,1962.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROBE LVL 05,2779957,CDM,272,RC,,,,,,,,inpatient,facility,,,3083,1294.86,2620.55,2959.68,,2620.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2682.21,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROBE LVL 05,2779957,CDM,272,RC,,,,,,,,outpatient,facility,,,3083,1294.86,832.41,3083,,2620.55,,,percent of total billed charges,,,832.41,,,percent of total billed charges,,,2121.1,,,percent of total billed charges,,,2074.86,,,percent of total billed charges,,,2605.13,,,percent of total billed charges,,,,,,,,,2682.21,,,percent of total billed charges,,,2682.21,,,percent of total billed charges,,,2620.55,,,percent of total billed charges,,,2959.68,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,2774.7,,,percent of total billed charges,,,,,,,,,2867.19,,,percent of total billed charges,,,2928.85,,,percent of total billed charges,,,,,,,,,,,,,,,3083,,,fee schedule,,,3083,,,fee schedule,,,3083,,,fee schedule,,,,,,,,,2407.82,,,percent of total billed charges,,,2805.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROBE LVL 06,2779965,CDM,272,RC,,,,,,,,inpatient,facility,,,3909,1641.78,3322.65,3752.64,,3322.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3400.83,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROBE LVL 06,2779965,CDM,272,RC,,,,,,,,outpatient,facility,,,3909,1641.78,1055.43,3909,,3322.65,,,percent of total billed charges,,,1055.43,,,percent of total billed charges,,,2689.39,,,percent of total billed charges,,,2630.76,,,percent of total billed charges,,,3303.11,,,percent of total billed charges,,,,,,,,,3400.83,,,percent of total billed charges,,,3400.83,,,percent of total billed charges,,,3322.65,,,percent of total billed charges,,,3752.64,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,3518.1,,,percent of total billed charges,,,,,,,,,3635.37,,,percent of total billed charges,,,3713.55,,,percent of total billed charges,,,,,,,,,,,,,,,3909,,,fee schedule,,,3909,,,fee schedule,,,3909,,,fee schedule,,,,,,,,,3052.93,,,percent of total billed charges,,,3557.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROBE LVL 07,2779973,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROBE LVL 07,2779973,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 06,2779981,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP VALVE LVL 06,2779981,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 06,2779999,CDM,278,RC,C1776,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP DEV JT TOE LVL 06,2779999,CDM,278,RC,C1776,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 05,2783801,CDM,272,RC,,,,,,,,inpatient,facility,,,2426,1018.92,2062.1,2328.96,,2062.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2110.62,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 05,2783801,CDM,272,RC,,,,,,,,outpatient,facility,,,2426,1018.92,655.02,2426,,2062.1,,,percent of total billed charges,,,655.02,,,percent of total billed charges,,,1669.09,,,percent of total billed charges,,,1632.7,,,percent of total billed charges,,,2049.97,,,percent of total billed charges,,,,,,,,,2110.62,,,percent of total billed charges,,,2110.62,,,percent of total billed charges,,,2062.1,,,percent of total billed charges,,,2328.96,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,2183.4,,,percent of total billed charges,,,,,,,,,2256.18,,,percent of total billed charges,,,2304.7,,,percent of total billed charges,,,,,,,,,,,,,,,2426,,,fee schedule,,,2426,,,fee schedule,,,2426,,,fee schedule,,,,,,,,,1894.71,,,percent of total billed charges,,,2207.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 06,2783819,CDM,272,RC,,,,,,,,inpatient,facility,,,2827,1187.34,2402.95,2713.92,,2402.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2459.49,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH CHOLANGIOGRAM LVL 06,2783819,CDM,272,RC,,,,,,,,outpatient,facility,,,2827,1187.34,763.29,2827,,2402.95,,,percent of total billed charges,,,763.29,,,percent of total billed charges,,,1944.98,,,percent of total billed charges,,,1902.57,,,percent of total billed charges,,,2388.82,,,percent of total billed charges,,,,,,,,,2459.49,,,percent of total billed charges,,,2459.49,,,percent of total billed charges,,,2402.95,,,percent of total billed charges,,,2713.92,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,2544.3,,,percent of total billed charges,,,,,,,,,2629.11,,,percent of total billed charges,,,2685.65,,,percent of total billed charges,,,,,,,,,,,,,,,2827,,,fee schedule,,,2827,,,fee schedule,,,2827,,,fee schedule,,,,,,,,,2207.89,,,percent of total billed charges,,,2572.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 08,2784411,CDM,272,RC,,,,,,,,inpatient,facility,,,8107,3404.94,6890.95,7782.72,,6890.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7053.09,,,percent of total billed charges,,,,,,,,,7296.3,,,percent of total billed charges,,,7782.72,,,percent of total billed charges,,,7701.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7539.51,,,percent of total billed charges,,,7701.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 08,2784411,CDM,272,RC,,,,,,,,outpatient,facility,,,8107,3404.94,2188.89,8107,,6890.95,,,percent of total billed charges,,,2188.89,,,percent of total billed charges,,,5577.62,,,percent of total billed charges,,,5456.01,,,percent of total billed charges,,,6850.41,,,percent of total billed charges,,,,,,,,,7053.09,,,percent of total billed charges,,,7053.09,,,percent of total billed charges,,,6890.95,,,percent of total billed charges,,,7782.72,,,percent of total billed charges,,,7701.65,,,percent of total billed charges,,,,,,,,,7296.3,,,percent of total billed charges,,,,,,,,,7539.51,,,percent of total billed charges,,,7701.65,,,percent of total billed charges,,,,,,,,,,,,,,,8107,,,fee schedule,,,8107,,,fee schedule,,,8107,,,fee schedule,,,,,,,,,6331.57,,,percent of total billed charges,,,7377.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FIX LW UP PELVIC LVL 09,2784973,CDM,278,RC,C1713,HCPCS,,,,,,inpatient,facility,,,30664,12878.88,26064.4,29437.44,,26064.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26677.68,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FIX LW UP PELVIC LVL 09,2784973,CDM,278,RC,C1713,HCPCS,,,,,,outpatient,facility,,,30664,12878.88,8279.28,30664,,26064.4,,,percent of total billed charges,,,8279.28,,,percent of total billed charges,,,21096.83,,,percent of total billed charges,,,20636.87,,,percent of total billed charges,,,25911.08,,,percent of total billed charges,,,,,,,,,26677.68,,,percent of total billed charges,,,26677.68,,,percent of total billed charges,,,26064.4,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,30664,,,fee schedule,,,30664,,,fee schedule,,,30664,,,fee schedule,,,,,,,,,23948.58,,,percent of total billed charges,,Paid in addition to outpatient services ,27904.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ENDOBRONCHIAL LVL 03,2785129,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ENDOBRONCHIAL LVL 03,2785129,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MAGGOTS MEDICAL VIAL LVL 05,2785137,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MAGGOTS MEDICAL VIAL LVL 05,2785137,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MAGGOTS MEDICAL VIAL LVL 06,2785145,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MAGGOTS MEDICAL VIAL LVL 06,2785145,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH INTRACARDIAC ECHO LVL 07,2785186,CDM,272,RC,C1759,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH INTRACARDIAC ECHO LVL 07,2785186,CDM,272,RC,C1759,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,,,,,,,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP CATH BRACHY SEED ADM LVL 07,2792398,CDM,278,RC,C1728,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP CATH BRACHY SEED ADM LVL 07,2792398,CDM,278,RC,C1728,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,,,,,,,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP W DEL LVL 06,2792406,CDM,278,RC,C2625,HCPCS,,,,,,inpatient,facility,,,6487,2724.54,5513.95,6227.52,,5513.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5643.69,,,percent of total billed charges,,,,,,,,,5838.3,,,percent of total billed charges,,,6227.52,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6032.91,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP STENT NONCOR TEMP W DEL LVL 06,2792406,CDM,278,RC,C2625,HCPCS,,,,,,outpatient,facility,,,6487,2724.54,1751.49,6487,,5513.95,,,percent of total billed charges,,,1751.49,,,percent of total billed charges,,,4463.06,,,percent of total billed charges,,,4365.75,,,percent of total billed charges,,,5481.51,,,percent of total billed charges,,,,,,,,,5643.69,,,percent of total billed charges,,,5643.69,,,percent of total billed charges,,,5513.95,,,percent of total billed charges,,,6227.52,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,5838.3,,,percent of total billed charges,,,,,,,,,6032.91,,,percent of total billed charges,,,6162.65,,,percent of total billed charges,,,,,,,,,,,,,,,6487,,,fee schedule,,,6487,,,fee schedule,,,6487,,,fee schedule,,,,,,,,,5066.35,,,percent of total billed charges,,Paid in addition to outpatient services ,5903.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP LD NEUROSTIM LVL 08,2792976,CDM,278,RC,C1778,HCPCS,,,,,,inpatient,facility,,,35044,14718.48,29787.4,33642.24,,29787.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30488.28,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP LD NEUROSTIM LVL 08,2792976,CDM,278,RC,C1778,HCPCS,,,,,,outpatient,facility,,,35044,14718.48,9461.88,35044,,29787.4,,,percent of total billed charges,,,9461.88,,,percent of total billed charges,,,24110.27,,,percent of total billed charges,,,23584.61,,,percent of total billed charges,,,29612.18,,,percent of total billed charges,,,,,,,,,30488.28,,,percent of total billed charges,,,30488.28,,,percent of total billed charges,,,29787.4,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,35044,,,fee schedule,,,35044,,,fee schedule,,,35044,,,fee schedule,,,,,,,,,27369.36,,,percent of total billed charges,,Paid in addition to outpatient services ,31890.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 09,2792984,CDM,272,RC,,,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HEMOSTATIC AGENT LVL 09,2792984,CDM,272,RC,,,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 01,2793552,CDM,272,RC,,,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 01,2793552,CDM,272,RC,,,,,,,,outpatient,facility,,,102,42.84,27.54,102,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,102,,,fee schedule,,,102,,,fee schedule,,,102,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 02,2793560,CDM,272,RC,,,,,,,,inpatient,facility,,,190,79.8,161.5,182.4,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.3,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 02,2793560,CDM,272,RC,,,,,,,,outpatient,facility,,,190,79.8,51.3,190,,161.5,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,130.72,,,percent of total billed charges,,,127.87,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,,,,,,,165.3,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,190,,,fee schedule,,,190,,,fee schedule,,,190,,,fee schedule,,,,,,,,,148.39,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 03,2793578,CDM,272,RC,,,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 03,2793578,CDM,272,RC,,,,,,,,outpatient,facility,,,313,131.46,84.51,313,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,244.45,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 04,2793586,CDM,272,RC,,,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 04,2793586,CDM,272,RC,,,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,,,,,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,,,,,,,463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 05,2793594,CDM,272,RC,,,,,,,,inpatient,facility,,,1413,593.46,1201.05,1356.48,,1201.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1229.31,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 05,2793594,CDM,272,RC,,,,,,,,outpatient,facility,,,1413,593.46,381.51,1413,,1201.05,,,percent of total billed charges,,,381.51,,,percent of total billed charges,,,972.14,,,percent of total billed charges,,,950.95,,,percent of total billed charges,,,1193.98,,,percent of total billed charges,,,,,,,,,1229.31,,,percent of total billed charges,,,1229.31,,,percent of total billed charges,,,1201.05,,,percent of total billed charges,,,1356.48,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,1271.7,,,percent of total billed charges,,,,,,,,,1314.09,,,percent of total billed charges,,,1342.35,,,percent of total billed charges,,,,,,,,,,,,,,,1413,,,fee schedule,,,1413,,,fee schedule,,,1413,,,fee schedule,,,,,,,,,1103.55,,,percent of total billed charges,,,1285.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 06,2793602,CDM,272,RC,,,,,,,,inpatient,facility,,,2695,1131.9,2290.75,2587.2,,2290.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2344.65,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 06,2793602,CDM,272,RC,,,,,,,,outpatient,facility,,,2695,1131.9,727.65,2695,,2290.75,,,percent of total billed charges,,,727.65,,,percent of total billed charges,,,1854.16,,,percent of total billed charges,,,1813.73,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,,,,,,,2344.65,,,percent of total billed charges,,,2344.65,,,percent of total billed charges,,,2290.75,,,percent of total billed charges,,,2587.2,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,2425.5,,,percent of total billed charges,,,,,,,,,2506.35,,,percent of total billed charges,,,2560.25,,,percent of total billed charges,,,,,,,,,,,,,,,2695,,,fee schedule,,,2695,,,fee schedule,,,2695,,,fee schedule,,,,,,,,,2104.79,,,percent of total billed charges,,,2452.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 07,2793610,CDM,272,RC,,,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 07,2793610,CDM,272,RC,,,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 08,2793628,CDM,272,RC,,,,,,,,inpatient,facility,,,4885,2051.7,4152.25,4689.6,,4152.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4249.95,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 08,2793628,CDM,272,RC,,,,,,,,outpatient,facility,,,4885,2051.7,1318.95,4885,,4152.25,,,percent of total billed charges,,,1318.95,,,percent of total billed charges,,,3360.88,,,percent of total billed charges,,,3287.6,,,percent of total billed charges,,,4127.82,,,percent of total billed charges,,,,,,,,,4249.95,,,percent of total billed charges,,,4249.95,,,percent of total billed charges,,,4152.25,,,percent of total billed charges,,,4689.6,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,4396.5,,,percent of total billed charges,,,,,,,,,4543.05,,,percent of total billed charges,,,4640.75,,,percent of total billed charges,,,,,,,,,,,,,,,4885,,,fee schedule,,,4885,,,fee schedule,,,4885,,,fee schedule,,,,,,,,,3815.18,,,percent of total billed charges,,,4445.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 09,2793636,CDM,272,RC,,,,,,,,inpatient,facility,,,6950,2919,5907.5,6672,,5907.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6046.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 09,2793636,CDM,272,RC,,,,,,,,outpatient,facility,,,6950,2919,1876.5,6950,,5907.5,,,percent of total billed charges,,,1876.5,,,percent of total billed charges,,,4781.6,,,percent of total billed charges,,,4677.35,,,percent of total billed charges,,,5872.75,,,percent of total billed charges,,,,,,,,,6046.5,,,percent of total billed charges,,,6046.5,,,percent of total billed charges,,,5907.5,,,percent of total billed charges,,,6672,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,6255,,,percent of total billed charges,,,,,,,,,6463.5,,,percent of total billed charges,,,6602.5,,,percent of total billed charges,,,,,,,,,,,,,,,6950,,,fee schedule,,,6950,,,fee schedule,,,6950,,,fee schedule,,,,,,,,,5427.95,,,percent of total billed charges,,,6324.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 10,2793644,CDM,272,RC,,,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 10,2793644,CDM,272,RC,,,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.97,,,percent of total billed charges,,,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 11,2793651,CDM,272,RC,,,,,,,,inpatient,facility,,,11580,4863.6,9843,11116.8,,9843,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10074.6,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 11,2793651,CDM,272,RC,,,,,,,,outpatient,facility,,,11580,4863.6,3126.6,11580,,9843,,,percent of total billed charges,,,3126.6,,,percent of total billed charges,,,7967.04,,,percent of total billed charges,,,7793.34,,,percent of total billed charges,,,9785.1,,,percent of total billed charges,,,,,,,,,10074.6,,,percent of total billed charges,,,10074.6,,,percent of total billed charges,,,9843,,,percent of total billed charges,,,11116.8,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,10422,,,percent of total billed charges,,,,,,,,,10769.4,,,percent of total billed charges,,,11001,,,percent of total billed charges,,,,,,,,,,,,,,,11580,,,fee schedule,,,11580,,,fee schedule,,,11580,,,fee schedule,,,,,,,,,9043.98,,,percent of total billed charges,,,10537.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 12,2793669,CDM,272,RC,,,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 12,2793669,CDM,272,RC,,,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10852,,,percent of total billed charges,,,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 13,2793677,CDM,272,RC,,,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 13,2793677,CDM,272,RC,,,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 14,2793685,CDM,272,RC,,,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 14,2793685,CDM,272,RC,,,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 15,2793693,CDM,272,RC,,,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 15,2793693,CDM,272,RC,,,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 16,2793701,CDM,272,RC,,,,,,,,inpatient,facility,,,30664,12878.88,26064.4,29437.44,,26064.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26677.68,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 16,2793701,CDM,272,RC,,,,,,,,outpatient,facility,,,30664,12878.88,8279.28,30664,,26064.4,,,percent of total billed charges,,,8279.28,,,percent of total billed charges,,,21096.83,,,percent of total billed charges,,,20636.87,,,percent of total billed charges,,,25911.08,,,percent of total billed charges,,,,,,,,,26677.68,,,percent of total billed charges,,,26677.68,,,percent of total billed charges,,,26064.4,,,percent of total billed charges,,,29437.44,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,27597.6,,,percent of total billed charges,,,,,,,,,28517.52,,,percent of total billed charges,,,29130.8,,,percent of total billed charges,,,,,,,,,,,,,,,30664,,,fee schedule,,,30664,,,fee schedule,,,30664,,,fee schedule,,,,,,,,,23948.58,,,percent of total billed charges,,,27904.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 17,2793719,CDM,272,RC,,,,,,,,inpatient,facility,,,35044,14718.48,29787.4,33642.24,,29787.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30488.28,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 17,2793719,CDM,272,RC,,,,,,,,outpatient,facility,,,35044,14718.48,9461.88,35044,,29787.4,,,percent of total billed charges,,,9461.88,,,percent of total billed charges,,,24110.27,,,percent of total billed charges,,,23584.61,,,percent of total billed charges,,,29612.18,,,percent of total billed charges,,,,,,,,,30488.28,,,percent of total billed charges,,,30488.28,,,percent of total billed charges,,,29787.4,,,percent of total billed charges,,,33642.24,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,31539.6,,,percent of total billed charges,,,,,,,,,32590.92,,,percent of total billed charges,,,33291.8,,,percent of total billed charges,,,,,,,,,,,,,,,35044,,,fee schedule,,,35044,,,fee schedule,,,35044,,,fee schedule,,,,,,,,,27369.36,,,percent of total billed charges,,,31890.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 18,2793727,CDM,272,RC,,,,,,,,inpatient,facility,,,43804,18397.68,37233.4,42051.84,,37233.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38109.48,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 18,2793727,CDM,272,RC,,,,,,,,outpatient,facility,,,43804,18397.68,11827.08,43804,,37233.4,,,percent of total billed charges,,,11827.08,,,percent of total billed charges,,,30137.15,,,percent of total billed charges,,,29480.09,,,percent of total billed charges,,,37014.38,,,percent of total billed charges,,,,,,,,,38109.48,,,percent of total billed charges,,,38109.48,,,percent of total billed charges,,,37233.4,,,percent of total billed charges,,,42051.84,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,39423.6,,,percent of total billed charges,,,,,,,,,40737.72,,,percent of total billed charges,,,41613.8,,,percent of total billed charges,,,,,,,,,,,,,,,43804,,,fee schedule,,,43804,,,fee schedule,,,43804,,,fee schedule,,,,,,,,,34210.92,,,percent of total billed charges,,,39861.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 19,2793735,CDM,272,RC,,,,,,,,inpatient,facility,,,52564,22076.88,44679.4,50461.44,,44679.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45730.68,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 19,2793735,CDM,272,RC,,,,,,,,outpatient,facility,,,52564,22076.88,14192.28,52564,,44679.4,,,percent of total billed charges,,,14192.28,,,percent of total billed charges,,,36164.03,,,percent of total billed charges,,,35375.57,,,percent of total billed charges,,,44416.58,,,percent of total billed charges,,,,,,,,,45730.68,,,percent of total billed charges,,,45730.68,,,percent of total billed charges,,,44679.4,,,percent of total billed charges,,,50461.44,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,47307.6,,,percent of total billed charges,,,,,,,,,48884.52,,,percent of total billed charges,,,49935.8,,,percent of total billed charges,,,,,,,,,,,,,,,52564,,,fee schedule,,,52564,,,fee schedule,,,52564,,,fee schedule,,,,,,,,,41052.48,,,percent of total billed charges,,,47833.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 20,2793743,CDM,272,RC,,,,,,,,inpatient,facility,,,61324,25756.08,52125.4,58871.04,,52125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53351.88,,,percent of total billed charges,,,,,,,,,55191.6,,,percent of total billed charges,,,58871.04,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57031.32,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 20,2793743,CDM,272,RC,,,,,,,,outpatient,facility,,,61324,25756.08,16557.48,61324,,52125.4,,,percent of total billed charges,,,16557.48,,,percent of total billed charges,,,42190.91,,,percent of total billed charges,,,41271.05,,,percent of total billed charges,,,51818.78,,,percent of total billed charges,,,,,,,,,53351.88,,,percent of total billed charges,,,53351.88,,,percent of total billed charges,,,52125.4,,,percent of total billed charges,,,58871.04,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,55191.6,,,percent of total billed charges,,,,,,,,,57031.32,,,percent of total billed charges,,,58257.8,,,percent of total billed charges,,,,,,,,,,,,,,,61324,,,fee schedule,,,61324,,,fee schedule,,,61324,,,fee schedule,,,,,,,,,47894.04,,,percent of total billed charges,,,55804.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 21,2793750,CDM,272,RC,,,,,,,,inpatient,facility,,,70084,29435.28,59571.4,67280.64,,59571.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60973.08,,,percent of total billed charges,,,,,,,,,63075.6,,,percent of total billed charges,,,67280.64,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65178.12,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 21,2793750,CDM,272,RC,,,,,,,,outpatient,facility,,,70084,29435.28,18922.68,70084,,59571.4,,,percent of total billed charges,,,18922.68,,,percent of total billed charges,,,48217.79,,,percent of total billed charges,,,47166.53,,,percent of total billed charges,,,59220.98,,,percent of total billed charges,,,,,,,,,60973.08,,,percent of total billed charges,,,60973.08,,,percent of total billed charges,,,59571.4,,,percent of total billed charges,,,67280.64,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,63075.6,,,percent of total billed charges,,,,,,,,,65178.12,,,percent of total billed charges,,,66579.8,,,percent of total billed charges,,,,,,,,,,,,,,,70084,,,fee schedule,,,70084,,,fee schedule,,,70084,,,fee schedule,,,,,,,,,54735.6,,,percent of total billed charges,,,63776.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 22,2793768,CDM,272,RC,,,,,,,,inpatient,facility,,,78844,33114.48,67017.4,75690.24,,67017.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68594.28,,,percent of total billed charges,,,,,,,,,70959.6,,,percent of total billed charges,,,75690.24,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73324.92,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 22,2793768,CDM,272,RC,,,,,,,,outpatient,facility,,,78844,33114.48,21287.88,78844,,67017.4,,,percent of total billed charges,,,21287.88,,,percent of total billed charges,,,54244.67,,,percent of total billed charges,,,53062.01,,,percent of total billed charges,,,66623.18,,,percent of total billed charges,,,,,,,,,68594.28,,,percent of total billed charges,,,68594.28,,,percent of total billed charges,,,67017.4,,,percent of total billed charges,,,75690.24,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,70959.6,,,percent of total billed charges,,,,,,,,,73324.92,,,percent of total billed charges,,,74901.8,,,percent of total billed charges,,,,,,,,,,,,,,,78844,,,fee schedule,,,78844,,,fee schedule,,,78844,,,fee schedule,,,,,,,,,61577.16,,,percent of total billed charges,,,71748.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 23,2793776,CDM,272,RC,,,,,,,,inpatient,facility,,,87604,36793.68,74463.4,84099.84,,74463.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76215.48,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 23,2793776,CDM,272,RC,,,,,,,,outpatient,facility,,,87604,36793.68,23653.08,87604,,74463.4,,,percent of total billed charges,,,23653.08,,,percent of total billed charges,,,60271.55,,,percent of total billed charges,,,58957.49,,,percent of total billed charges,,,74025.38,,,percent of total billed charges,,,,,,,,,76215.48,,,percent of total billed charges,,,76215.48,,,percent of total billed charges,,,74463.4,,,percent of total billed charges,,,84099.84,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,78843.6,,,percent of total billed charges,,,,,,,,,81471.72,,,percent of total billed charges,,,83223.8,,,percent of total billed charges,,,,,,,,,,,,,,,87604,,,fee schedule,,,87604,,,fee schedule,,,87604,,,fee schedule,,,,,,,,,68418.72,,,percent of total billed charges,,,79719.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 24,2793784,CDM,272,RC,,,,,,,,inpatient,facility,,,96364,40472.88,81909.4,92509.44,,81909.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83836.68,,,percent of total billed charges,,,,,,,,,86727.6,,,percent of total billed charges,,,92509.44,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89618.52,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FIX EXTRNL LW UP PELVIC LVL 24,2793784,CDM,272,RC,,,,,,,,outpatient,facility,,,96364,40472.88,26018.28,96364,,81909.4,,,percent of total billed charges,,,26018.28,,,percent of total billed charges,,,66298.43,,,percent of total billed charges,,,64852.97,,,percent of total billed charges,,,81427.58,,,percent of total billed charges,,,,,,,,,83836.68,,,percent of total billed charges,,,83836.68,,,percent of total billed charges,,,81909.4,,,percent of total billed charges,,,92509.44,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,86727.6,,,percent of total billed charges,,,,,,,,,89618.52,,,percent of total billed charges,,,91545.8,,,percent of total billed charges,,,,,,,,,,,,,,,96364,,,fee schedule,,,96364,,,fee schedule,,,96364,,,fee schedule,,,,,,,,,75260.28,,,percent of total billed charges,,,87691.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DEVICE HEART ARTIFICIAL 70CC,2793875,CDM,278,RC,L8699,HCPCS,,,,,,inpatient,facility,,,744600,312732,632910,714816,,632910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,647802,,,percent of total billed charges,,,,,,,,,670140,,,percent of total billed charges,,,714816,,,percent of total billed charges,,,707370,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,692478,,,percent of total billed charges,,,707370,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE HEART ARTIFICIAL 70CC,2793875,CDM,278,RC,L8699,HCPCS,,,,,,outpatient,facility,,,744600,312732,201042,744600,,632910,,,percent of total billed charges,,,201042,,,percent of total billed charges,,,512284.8,,,percent of total billed charges,,,501115.8,,,percent of total billed charges,,,629187,,,percent of total billed charges,,,,,,,,,647802,,,percent of total billed charges,,,647802,,,percent of total billed charges,,,632910,,,percent of total billed charges,,,714816,,,percent of total billed charges,,,707370,,,percent of total billed charges,,,,,,,,,670140,,,percent of total billed charges,,,,,,,,,692478,,,percent of total billed charges,,,707370,,,percent of total billed charges,,,,,,,,,,,,,,,744600,,,fee schedule,,,744600,,,fee schedule,,,744600,,,fee schedule,,,,,,,,,581532.6,,,percent of total billed charges,,Paid in addition to outpatient services ,677586,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 01,2794030,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,3853,1618.26,3275.05,3698.88,,3275.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3352.11,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 01,2794030,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,3853,1618.26,1040.31,3853,,3275.05,,,percent of total billed charges,,,1040.31,,,percent of total billed charges,,,2650.86,,,percent of total billed charges,,,2593.07,,,percent of total billed charges,,,3255.78,,,percent of total billed charges,,,,,,,,,3352.11,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,3275.05,,,percent of total billed charges,,,3698.88,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,3467.7,,,percent of total billed charges,,,,,,,,,3583.29,,,percent of total billed charges,,,3660.35,,,percent of total billed charges,,,,,,,,,,,,,,,3853,,,fee schedule,,,3853,,,fee schedule,,,3853,,,fee schedule,,,,,,,,,3009.19,,,percent of total billed charges,,,3506.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 02,2794048,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,6105,2564.1,5189.25,5860.8,,5189.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5311.35,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 02,2794048,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,6105,2564.1,1648.35,6105,,5189.25,,,percent of total billed charges,,,1648.35,,,percent of total billed charges,,,4200.24,,,percent of total billed charges,,,4108.66,,,percent of total billed charges,,,5158.72,,,percent of total billed charges,,,,,,,,,5311.35,,,percent of total billed charges,,,5311.35,,,percent of total billed charges,,,5189.25,,,percent of total billed charges,,,5860.8,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,5494.5,,,percent of total billed charges,,,,,,,,,5677.65,,,percent of total billed charges,,,5799.75,,,percent of total billed charges,,,,,,,,,,,,,,,6105,,,fee schedule,,,6105,,,fee schedule,,,6105,,,fee schedule,,,,,,,,,4768,,,percent of total billed charges,,Paid in addition to outpatient services ,5555.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 03,2794055,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,9265,3891.3,7875.25,8894.4,,7875.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8060.55,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 03,2794055,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,9265,3891.3,2501.55,9265,,7875.25,,,percent of total billed charges,,,2501.55,,,percent of total billed charges,,,6374.32,,,percent of total billed charges,,,6235.34,,,percent of total billed charges,,,7828.93,,,percent of total billed charges,,,,,,,,,8060.55,,,percent of total billed charges,,,8060.55,,,percent of total billed charges,,,7875.25,,,percent of total billed charges,,,8894.4,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,8338.5,,,percent of total billed charges,,,,,,,,,8616.45,,,percent of total billed charges,,,8801.75,,,percent of total billed charges,,,,,,,,,,,,,,,9265,,,fee schedule,,,9265,,,fee schedule,,,9265,,,fee schedule,,,,,,,,,7235.96,,,percent of total billed charges,,Paid in addition to outpatient services ,8431.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 04,2794063,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,13895,5835.9,11810.75,13339.2,,11810.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12088.65,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 04,2794063,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,13895,5835.9,3751.65,13895,,11810.75,,,percent of total billed charges,,,3751.65,,,percent of total billed charges,,,9559.76,,,percent of total billed charges,,,9351.33,,,percent of total billed charges,,,11741.27,,,percent of total billed charges,,,,,,,,,12088.65,,,percent of total billed charges,,,12088.65,,,percent of total billed charges,,,11810.75,,,percent of total billed charges,,,13339.2,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,12505.5,,,percent of total billed charges,,,,,,,,,12922.35,,,percent of total billed charges,,,13200.25,,,percent of total billed charges,,,,,,,,,,,,,,,13895,,,fee schedule,,,13895,,,fee schedule,,,13895,,,fee schedule,,,,,,,,,10851.99,,,percent of total billed charges,,Paid in addition to outpatient services ,12644.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 05,2794071,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,17524,7360.08,14895.4,16823.04,,14895.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15245.88,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 05,2794071,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,17524,7360.08,4731.48,17524,,14895.4,,,percent of total billed charges,,,4731.48,,,percent of total billed charges,,,12056.51,,,percent of total billed charges,,,11793.65,,,percent of total billed charges,,,14807.78,,,percent of total billed charges,,,,,,,,,15245.88,,,percent of total billed charges,,,15245.88,,,percent of total billed charges,,,14895.4,,,percent of total billed charges,,,16823.04,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,15771.6,,,percent of total billed charges,,,,,,,,,16297.32,,,percent of total billed charges,,,16647.8,,,percent of total billed charges,,,,,,,,,,,,,,,17524,,,fee schedule,,,17524,,,fee schedule,,,17524,,,fee schedule,,,,,,,,,13686.24,,,percent of total billed charges,,Paid in addition to outpatient services ,15946.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 06,2794089,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,21904,9199.68,18618.4,21027.84,,18618.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19056.48,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 06,2794089,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,21904,9199.68,5914.08,21904,,18618.4,,,percent of total billed charges,,,5914.08,,,percent of total billed charges,,,15069.95,,,percent of total billed charges,,,14741.39,,,percent of total billed charges,,,18508.88,,,percent of total billed charges,,,,,,,,,19056.48,,,percent of total billed charges,,,19056.48,,,percent of total billed charges,,,18618.4,,,percent of total billed charges,,,21027.84,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,19713.6,,,percent of total billed charges,,,,,,,,,20370.72,,,percent of total billed charges,,,20808.8,,,percent of total billed charges,,,,,,,,,,,,,,,21904,,,fee schedule,,,21904,,,fee schedule,,,21904,,,fee schedule,,,,,,,,,17107.02,,,percent of total billed charges,,Paid in addition to outpatient services ,19932.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 07,2794097,CDM,278,RC,C1889,HCPCS,,,,,,inpatient,facility,,,26284,11039.28,22341.4,25232.64,,22341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22867.08,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP FASTENERS W DEV DELIVERY LVL 07,2794097,CDM,278,RC,C1889,HCPCS,,,,,,outpatient,facility,,,26284,11039.28,7096.68,26284,,22341.4,,,percent of total billed charges,,,7096.68,,,percent of total billed charges,,,18083.39,,,percent of total billed charges,,,17689.13,,,percent of total billed charges,,,22209.98,,,percent of total billed charges,,,,,,,,,22867.08,,,percent of total billed charges,,,22867.08,,,percent of total billed charges,,,22341.4,,,percent of total billed charges,,,25232.64,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,23655.6,,,percent of total billed charges,,,,,,,,,24444.12,,,percent of total billed charges,,,24969.8,,,percent of total billed charges,,,,,,,,,,,,,,,26284,,,fee schedule,,,26284,,,fee schedule,,,26284,,,fee schedule,,,,,,,,,20527.8,,,percent of total billed charges,,Paid in addition to outpatient services ,23918.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 07,2799443,CDM,278,RC,C2622,HCPCS,,,,,,inpatient,facility,,,41614,17477.88,35371.9,39949.44,,35371.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36204.18,,,percent of total billed charges,,,,,,,,,37452.6,,,percent of total billed charges,,,39949.44,,,percent of total billed charges,,,39533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38701.02,,,percent of total billed charges,,,39533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMP PROSTH PENILE NONINF LVL 07,2799443,CDM,278,RC,C2622,HCPCS,,,,,,outpatient,facility,,,41614,17477.88,11235.78,41614,,35371.9,,,percent of total billed charges,,,11235.78,,,percent of total billed charges,,,28630.43,,,percent of total billed charges,,,28006.22,,,percent of total billed charges,,,35163.83,,,percent of total billed charges,,,,,,,,,36204.18,,,percent of total billed charges,,,36204.18,,,percent of total billed charges,,,35371.9,,,percent of total billed charges,,,39949.44,,,percent of total billed charges,,,39533.3,,,percent of total billed charges,,,,,,,,,37452.6,,,percent of total billed charges,,,,,,,,,38701.02,,,percent of total billed charges,,,39533.3,,,percent of total billed charges,,,,,,,,,,,,,,,41614,,,fee schedule,,,41614,,,fee schedule,,,41614,,,fee schedule,,,,,,,,,32500.53,,,percent of total billed charges,,Paid in addition to outpatient services ,37868.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB IG FREE LIGHT CHAIN SERUM EA,3000007,CDM,301,RC,83521,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG FREE LIGHT CHAIN SERUM EA,3000007,CDM,301,RC,83521,CPT,,,,,,outpatient,facility,,,61,25.62,15.03,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,17.27,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,17.27,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,17.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT ETEST AGENT EA NS,3020112,CDM,306,RC,87181,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT ETEST AGENT EA NS,3020112,CDM,306,RC,87181,CPT,,,,,,outpatient,facility,,,66,27.72,4.14,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,4.75,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,4.75,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,6.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.41,,,fee schedule,,,4.22,,,fee schedule,,,4.22,,,fee schedule,,,4.14,,,fee schedule,,,4.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,4.75,,,fee schedule,,,4.75,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUGARS SINGLE QL STOOL NS,3020120,CDM,301,RC,84376,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUGARS SINGLE QL STOOL NS,3020120,CDM,301,RC,84376,CPT,,,,,,outpatient,facility,,,64,26.88,4.78,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,5.5,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,5.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,5.5,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,7.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.43,,,fee schedule,,,4.88,,,fee schedule,,,4.88,,,fee schedule,,,4.78,,,fee schedule,,,5.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,5.5,,,fee schedule,,,5.5,,,fee schedule,,,6.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LEUKOCYTE HISTAMINE RELEASE,3020922,CDM,302,RC,86343,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LEUKOCYTE HISTAMINE RELEASE,3020922,CDM,302,RC,86343,CPT,,,,,,outpatient,facility,,,64,26.88,10.84,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,12.46,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,12.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,12.46,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,18.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.82,,,fee schedule,,,11.06,,,fee schedule,,,11.06,,,fee schedule,,,10.84,,,fee schedule,,,12.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,12.46,,,fee schedule,,,12.46,,,fee schedule,,,15.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB SYPHILIS,3021243,CDM,302,RC,86780,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB SYPHILIS,3021243,CDM,302,RC,86780,CPT,,,,,,outpatient,facility,,,53,22.26,11.52,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,13.24,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,13.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,13.24,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,19.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.87,,,fee schedule,,,11.76,,,fee schedule,,,11.76,,,fee schedule,,,11.52,,,fee schedule,,,13.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,13.24,,,fee schedule,,,13.24,,,fee schedule,,,15.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB NEUROMYOTONIA FL,3022209,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB NEUROMYOTONIA FL,3022209,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.05,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHOLINESTERASE SERUM NS,3022373,CDM,301,RC,82480,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHOLINESTERASE SERUM NS,3022373,CDM,301,RC,82480,CPT,,,,,,outpatient,facility,,,61,25.62,6.85,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,7.87,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,8.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,7.87,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,11.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.62,,,fee schedule,,,6.99,,,fee schedule,,,6.99,,,fee schedule,,,6.85,,,fee schedule,,,7.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,7.87,,,fee schedule,,,7.87,,,fee schedule,,,9.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB EVEROLIMUS,3022472,CDM,301,RC,80169,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB EVEROLIMUS,3022472,CDM,301,RC,80169,CPT,,,,,,outpatient,facility,,,60,25.2,11.95,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,13.73,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,13.73,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,19.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.54,,,fee schedule,,,12.19,,,fee schedule,,,12.19,,,fee schedule,,,11.95,,,fee schedule,,,13.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,13.73,,,fee schedule,,,13.73,,,fee schedule,,,16.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HORMONE ANTIMULLERIAN,3022720,CDM,301,RC,82166,CPT,,,,,,inpatient,facility,,,116,48.72,98.6,111.36,,98.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,104.4,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HORMONE ANTIMULLERIAN,3022720,CDM,301,RC,82166,CPT,,,,,,outpatient,facility,,,116,48.72,31.32,111.36,,98.6,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,79.81,,,percent of total billed charges,,,78.07,,,percent of total billed charges,,,98.02,,,percent of total billed charges,,,38.62,,,fee schedule,,,100.92,,,percent of total billed charges,,,100.92,,,percent of total billed charges,,,98.6,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,39.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",104.4,,,percent of total billed charges,,,38.62,,,fee schedule,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.14,,,fee schedule,,,34.29,,,fee schedule,,,34.29,,,fee schedule,,,33.6,,,fee schedule,,,38.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",90.6,,,percent of total billed charges,,,105.56,,,percent of total billed charges,,,38.62,,,fee schedule,,,38.62,,,fee schedule,,,,,,,,
LAB AB HEPATITIS C NS,3022746,CDM,302,RC,86803,CPT,,,,,,inpatient,facility,,,255,107.1,216.75,244.8,,216.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.85,,,percent of total billed charges,,,,,,,,,229.5,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.15,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS C NS,3022746,CDM,302,RC,86803,CPT,,,,,,outpatient,facility,,,255,107.1,12.42,244.8,,216.75,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,175.44,,,percent of total billed charges,,,171.61,,,percent of total billed charges,,,215.47,,,percent of total billed charges,,,14.27,,,fee schedule,,,221.85,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,,216.75,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,14.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",229.5,,,percent of total billed charges,,,14.27,,,fee schedule,,,237.15,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,20.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.26,,,fee schedule,,,12.67,,,fee schedule,,,12.67,,,fee schedule,,,12.42,,,fee schedule,,,14.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",199.16,,,percent of total billed charges,,,232.05,,,percent of total billed charges,,,14.27,,,fee schedule,,,14.27,,,fee schedule,,,17.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC AGGREGATION PLT EA AGENT,3022779,CDM,305,RC,85576,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC AGGREGATION PLT EA AGENT,3022779,CDM,305,RC,85576,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,24.91,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,25.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,24.91,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,36.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.63,,,fee schedule,,,22.12,,,fee schedule,,,22.12,,,fee schedule,,,21.68,,,fee schedule,,,24.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,24.91,,,fee schedule,,,24.91,,,fee schedule,,,26.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC FIBRINOGEN ACTIVITY,3022787,CDM,305,RC,85384,CPT,,,,,,inpatient,facility,,,30,12.6,25.5,28.8,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,27,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC FIBRINOGEN ACTIVITY,3022787,CDM,305,RC,85384,CPT,,,,,,outpatient,facility,,,30,12.6,8.1,28.8,,25.5,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,20.64,,,percent of total billed charges,,,20.19,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,9.72,,,fee schedule,,,26.1,,,percent of total billed charges,,,26.1,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27,,,percent of total billed charges,,,9.72,,,fee schedule,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,14.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.12,,,fee schedule,,,8.63,,,fee schedule,,,8.63,,,fee schedule,,,8.46,,,fee schedule,,,9.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",23.43,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,9.72,,,fee schedule,,,9.72,,,fee schedule,,,10.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC SCR FIBRINOLYSINS COAG,3022795,CDM,305,RC,85390,CPT,,,,,,inpatient,facility,,,47,19.74,39.95,45.12,,39.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.89,,,percent of total billed charges,,,,,,,,,42.3,,,percent of total billed charges,,,45.12,,,percent of total billed charges,,,44.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,43.71,,,percent of total billed charges,,,44.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC SCR FIBRINOLYSINS COAG,3022795,CDM,305,RC,85390,CPT,,,,,,outpatient,facility,,,47,19.74,2.06,45.12,,39.95,,,percent of total billed charges,,,12.69,,,percent of total billed charges,,,32.34,,,percent of total billed charges,,,31.63,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,15.48,,,fee schedule,,,40.89,,,percent of total billed charges,,,40.89,,,percent of total billed charges,,,39.95,,,percent of total billed charges,,,45.12,,,percent of total billed charges,,,44.65,,,percent of total billed charges,,,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",42.3,,,percent of total billed charges,,,15.48,,,fee schedule,,,43.71,,,percent of total billed charges,,,44.65,,,percent of total billed charges,,,22.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.9,,,fee schedule,,,13.75,,,fee schedule,,,13.75,,,fee schedule,,,13.48,,,fee schedule,,,15.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",36.71,,,percent of total billed charges,,,42.77,,,percent of total billed charges,,,15.48,,,fee schedule,,,15.48,,,fee schedule,,,2.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ID ANTI NEUTROPHIL,3022878,CDM,302,RC,86021,CPT,,,,,,inpatient,facility,,,46,19.32,39.1,44.16,,39.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.02,,,percent of total billed charges,,,,,,,,,41.4,,,percent of total billed charges,,,44.16,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.78,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ID ANTI NEUTROPHIL,3022878,CDM,302,RC,86021,CPT,,,,,,outpatient,facility,,,46,19.32,12.42,44.16,,39.1,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,30.96,,,percent of total billed charges,,,38.87,,,percent of total billed charges,,,15.05,,,fee schedule,,,40.02,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,39.1,,,percent of total billed charges,,,44.16,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,15.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.4,,,percent of total billed charges,,,15.05,,,fee schedule,,,42.78,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.32,,,fee schedule,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,13.09,,,fee schedule,,,15.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",35.93,,,percent of total billed charges,,,41.86,,,percent of total billed charges,,,15.05,,,fee schedule,,,15.05,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MCG IN SITU INT 25 99 CELL NS,3022886,CDM,311,RC,88274,CPT,,,,,,inpatient,facility,,,128,53.76,108.8,122.88,,108.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.36,,,percent of total billed charges,,,,,,,,,115.2,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MCG IN SITU INT 25 99 CELL NS,3022886,CDM,311,RC,88274,CPT,,,,,,outpatient,facility,,,128,53.76,34.56,122.88,,108.8,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,88.06,,,percent of total billed charges,,,86.14,,,percent of total billed charges,,,108.16,,,percent of total billed charges,,,42.38,,,fee schedule,,,111.36,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,108.8,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,43.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",115.2,,,percent of total billed charges,,,42.38,,,fee schedule,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,61.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.21,,,fee schedule,,,37.63,,,fee schedule,,,37.63,,,fee schedule,,,36.88,,,fee schedule,,,42.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.97,,,percent of total billed charges,,,116.48,,,percent of total billed charges,,,42.38,,,fee schedule,,,42.38,,,fee schedule,,,42.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HIV 1 PRB AMP NS,3023199,CDM,306,RC,87535,CPT,,,,,,inpatient,facility,,,108,45.36,91.8,103.68,,91.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.96,,,percent of total billed charges,,,,,,,,,97.2,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HIV 1 PRB AMP NS,3023199,CDM,306,RC,87535,CPT,,,,,,outpatient,facility,,,108,45.36,29.16,103.68,,91.8,,,percent of total billed charges,,,29.16,,,percent of total billed charges,,,74.3,,,percent of total billed charges,,,72.68,,,percent of total billed charges,,,91.26,,,percent of total billed charges,,,35.09,,,fee schedule,,,93.96,,,percent of total billed charges,,,93.96,,,percent of total billed charges,,,91.8,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.2,,,percent of total billed charges,,,35.09,,,fee schedule,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",84.35,,,percent of total billed charges,,,98.28,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA ENTEROVRS PRB AMP,3023348,CDM,306,RC,87498,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA ENTEROVRS PRB AMP,3023348,CDM,306,RC,87498,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA ENTEROVRS PRB AMP NS,3023355,CDM,306,RC,87498,CPT,,,,,,inpatient,facility,,,139,58.38,118.15,133.44,,118.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.93,,,percent of total billed charges,,,,,,,,,125.1,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA ENTEROVRS PRB AMP NS,3023355,CDM,306,RC,87498,CPT,,,,,,outpatient,facility,,,139,58.38,30.54,133.44,,118.15,,,percent of total billed charges,,,37.53,,,percent of total billed charges,,,95.63,,,percent of total billed charges,,,93.55,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,35.09,,,fee schedule,,,120.93,,,percent of total billed charges,,,120.93,,,percent of total billed charges,,,118.15,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.1,,,percent of total billed charges,,,35.09,,,fee schedule,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",108.56,,,percent of total billed charges,,,126.49,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FETAL CONGENITAL ABNORMALITIES,3023462,CDM,310,RC,81508,CPT,,,,,,inpatient,facility,,,260,109.2,221,249.6,,221,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,226.2,,,percent of total billed charges,,,,,,,,,234,,,percent of total billed charges,,,249.6,,,percent of total billed charges,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,241.8,,,percent of total billed charges,,,247,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FETAL CONGENITAL ABNORMALITIES,3023462,CDM,310,RC,81508,CPT,,,,,,outpatient,facility,,,260,109.2,54.3,249.6,,221,,,percent of total billed charges,,,70.2,,,percent of total billed charges,,,178.88,,,percent of total billed charges,,,174.98,,,percent of total billed charges,,,219.7,,,percent of total billed charges,,,54.3,,,fee schedule,,,226.2,,,percent of total billed charges,,,226.2,,,percent of total billed charges,,,221,,,percent of total billed charges,,,249.6,,,percent of total billed charges,,,247,,,percent of total billed charges,,,55.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",234,,,percent of total billed charges,,,54.3,,,fee schedule,,,241.8,,,percent of total billed charges,,,247,,,percent of total billed charges,,,78.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",73.31,,,fee schedule,,,58.93,,,fee schedule,,,58.93,,,fee schedule,,,57.75,,,fee schedule,,,54.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",203.06,,,percent of total billed charges,,,236.6,,,percent of total billed charges,,,54.3,,,fee schedule,,,54.3,,,fee schedule,,,,,,,,
LAB DET IA RESP MLTPLX 12 25 TGT NS,3024049,CDM,306,RC,87633,CPT,,,,,,inpatient,facility,,,1251,525.42,1063.35,1200.96,,1063.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.37,,,percent of total billed charges,,,,,,,,,1125.9,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA RESP MLTPLX 12 25 TGT NS,3024049,CDM,306,RC,87633,CPT,,,,,,outpatient,facility,,,1251,525.42,337.77,1200.96,,1063.35,,,percent of total billed charges,,,337.77,,,percent of total billed charges,,,860.69,,,percent of total billed charges,,,841.92,,,percent of total billed charges,,,1057.1,,,percent of total billed charges,,,416.78,,,fee schedule,,,1088.37,,,percent of total billed charges,,,1088.37,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,425.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1125.9,,,percent of total billed charges,,,416.78,,,fee schedule,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,604.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.65,,,fee schedule,,,370.1,,,fee schedule,,,370.1,,,fee schedule,,,362.7,,,fee schedule,,,416.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",977.03,,,percent of total billed charges,,,1138.41,,,percent of total billed charges,,,416.78,,,fee schedule,,,416.78,,,fee schedule,,,502.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA FLU REV T ANDPRB AMP 1 2,3024114,CDM,306,RC,87502,CPT,,,,,,inpatient,facility,,,288,120.96,244.8,276.48,,244.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.56,,,percent of total billed charges,,,,,,,,,259.2,,,percent of total billed charges,,,276.48,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.84,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA FLU REV T ANDPRB AMP 1 2,3024114,CDM,306,RC,87502,CPT,,,,,,outpatient,facility,,,288,120.96,77.76,276.48,,244.8,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,198.14,,,percent of total billed charges,,,193.82,,,percent of total billed charges,,,243.36,,,percent of total billed charges,,,95.8,,,fee schedule,,,250.56,,,percent of total billed charges,,,250.56,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,276.48,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,97.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",259.2,,,percent of total billed charges,,,95.8,,,fee schedule,,,267.84,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,138.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",129.33,,,fee schedule,,,85.07,,,fee schedule,,,85.07,,,fee schedule,,,83.37,,,fee schedule,,,95.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",224.93,,,percent of total billed charges,,,262.08,,,percent of total billed charges,,,95.8,,,fee schedule,,,95.8,,,fee schedule,,,101.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AG BLD TYPE SERUM PT U NS,3024270,CDM,300,RC,86904,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AG BLD TYPE SERUM PT U NS,3024270,CDM,300,RC,86904,CPT,,,,,,outpatient,facility,,,153,64.26,41.31,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,,,,,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,61.17,,,fee schedule,,,,,,,,,119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB SCR AG BLD TYPE SERUM PT U NS,3024270,CDM,300,RC,86904,CPT,5733,APC,,,,outpatient,facility,,,153,153,31.22,90.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,90.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,62.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,31.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HEP C PRB AMP,3024387,CDM,306,RC,87521,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HEP C PRB AMP,3024387,CDM,306,RC,87521,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HEP C QN,3024395,CDM,306,RC,87522,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HEP C QN,3024395,CDM,306,RC,87522,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HIV 1 QN,3024403,CDM,306,RC,87536,CPT,,,,,,inpatient,facility,,,256,107.52,217.6,245.76,,217.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HIV 1 QN,3024403,CDM,306,RC,87536,CPT,,,,,,outpatient,facility,,,256,107.52,69.12,245.76,,217.6,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,176.13,,,percent of total billed charges,,,172.29,,,percent of total billed charges,,,216.32,,,percent of total billed charges,,,85.1,,,fee schedule,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,217.6,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,86.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",230.4,,,percent of total billed charges,,,85.1,,,fee schedule,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,123.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",114.89,,,fee schedule,,,75.57,,,fee schedule,,,75.57,,,fee schedule,,,74.06,,,fee schedule,,,85.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",199.94,,,percent of total billed charges,,,232.96,,,percent of total billed charges,,,85.1,,,fee schedule,,,85.1,,,fee schedule,,,104.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HEP C QN NS,3024411,CDM,306,RC,87522,CPT,,,,,,inpatient,facility,,,147,61.74,124.95,141.12,,124.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.89,,,percent of total billed charges,,,,,,,,,132.3,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.71,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HEP C QN NS,3024411,CDM,306,RC,87522,CPT,,,,,,outpatient,facility,,,147,61.74,37.28,141.12,,124.95,,,percent of total billed charges,,,39.69,,,percent of total billed charges,,,101.14,,,percent of total billed charges,,,98.93,,,percent of total billed charges,,,124.21,,,percent of total billed charges,,,42.84,,,fee schedule,,,127.89,,,percent of total billed charges,,,127.89,,,percent of total billed charges,,,124.95,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",132.3,,,percent of total billed charges,,,42.84,,,fee schedule,,,136.71,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",114.81,,,percent of total billed charges,,,133.77,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE F2 VAR 20210G MORE THANA,3025111,CDM,310,RC,81240,CPT,,,,,,inpatient,facility,,,198,83.16,168.3,190.08,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.26,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,190.08,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE F2 VAR 20210G MORE THANA,3025111,CDM,310,RC,81240,CPT,,,,,,outpatient,facility,,,198,83.16,53.46,190.08,,168.3,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,136.22,,,percent of total billed charges,,,133.25,,,percent of total billed charges,,,167.31,,,percent of total billed charges,,,65.69,,,fee schedule,,,172.26,,,percent of total billed charges,,,172.26,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,190.08,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",178.2,,,percent of total billed charges,,,65.69,,,fee schedule,,,184.14,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,95.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.68,,,fee schedule,,,58.33,,,fee schedule,,,58.33,,,fee schedule,,,57.16,,,fee schedule,,,65.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",154.64,,,percent of total billed charges,,,180.18,,,percent of total billed charges,,,65.69,,,fee schedule,,,65.69,,,fee schedule,,,57.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA RESP MLTPLX 6 11 TGT,3025426,CDM,306,RC,87632,CPT,,,,,,inpatient,facility,,,655,275.1,556.75,628.8,,556.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,569.85,,,percent of total billed charges,,,,,,,,,589.5,,,percent of total billed charges,,,628.8,,,percent of total billed charges,,,622.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,609.15,,,percent of total billed charges,,,622.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA RESP MLTPLX 6 11 TGT,3025426,CDM,306,RC,87632,CPT,,,,,,outpatient,facility,,,655,275.1,176.85,628.8,,556.75,,,percent of total billed charges,,,176.85,,,percent of total billed charges,,,450.64,,,percent of total billed charges,,,440.81,,,percent of total billed charges,,,553.48,,,percent of total billed charges,,,218.06,,,fee schedule,,,569.85,,,percent of total billed charges,,,569.85,,,percent of total billed charges,,,556.75,,,percent of total billed charges,,,628.8,,,percent of total billed charges,,,622.25,,,percent of total billed charges,,,222.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",589.5,,,percent of total billed charges,,,218.06,,,fee schedule,,,609.15,,,percent of total billed charges,,,622.25,,,percent of total billed charges,,,316.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",294.38,,,fee schedule,,,193.64,,,fee schedule,,,193.64,,,fee schedule,,,189.77,,,fee schedule,,,218.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",511.55,,,percent of total billed charges,,,596.05,,,percent of total billed charges,,,218.06,,,fee schedule,,,218.06,,,fee schedule,,,257.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA VZV PCR PRB AMP,3025558,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA VZV PCR PRB AMP,3025558,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA RESP MLTPLX 3 5 TGT,3025889,CDM,306,RC,87631,CPT,,,,,,inpatient,facility,,,428,179.76,363.8,410.88,,363.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.36,,,percent of total billed charges,,,,,,,,,385.2,,,percent of total billed charges,,,410.88,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.04,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA RESP MLTPLX 3 5 TGT,3025889,CDM,306,RC,87631,CPT,,,,,,outpatient,facility,,,428,179.76,115.56,410.88,,363.8,,,percent of total billed charges,,,115.56,,,percent of total billed charges,,,294.46,,,percent of total billed charges,,,288.04,,,percent of total billed charges,,,361.66,,,percent of total billed charges,,,142.63,,,fee schedule,,,372.36,,,percent of total billed charges,,,372.36,,,percent of total billed charges,,,363.8,,,percent of total billed charges,,,410.88,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,145.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",385.2,,,percent of total billed charges,,,142.63,,,fee schedule,,,398.04,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,206.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",192.55,,,fee schedule,,,126.66,,,fee schedule,,,126.66,,,fee schedule,,,124.13,,,fee schedule,,,142.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",334.27,,,percent of total billed charges,,,389.48,,,percent of total billed charges,,,142.63,,,fee schedule,,,142.63,,,fee schedule,,,154.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE SEQ MUTATION FAM TARGETED,3025905,CDM,310,RC,81479,CPT,,,,,,inpatient,facility,,,401,168.42,340.85,384.96,,340.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,348.87,,,percent of total billed charges,,,,,,,,,360.9,,,percent of total billed charges,,,384.96,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,372.93,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE SEQ MUTATION FAM TARGETED,3025905,CDM,310,RC,81479,CPT,,,,,,outpatient,facility,,,401,168.42,108.27,401,,340.85,,,percent of total billed charges,,,108.27,,,percent of total billed charges,,,275.89,,,percent of total billed charges,,,269.87,,,percent of total billed charges,,,338.84,,,percent of total billed charges,,,,,,,,,348.87,,,percent of total billed charges,,,348.87,,,percent of total billed charges,,,340.85,,,percent of total billed charges,,,384.96,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,360.9,,,percent of total billed charges,,,,,,,,,372.93,,,percent of total billed charges,,,380.95,,,percent of total billed charges,,,,,,,,,,,,,,,401,,,fee schedule,,,401,,,fee schedule,,,392.98,,,fee schedule,,,,,,,,,313.18,,,percent of total billed charges,,,364.91,,,percent of total billed charges,,,,,,,,,,,,,,,280.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HISTOPLASMA COMP FIXATION,3026051,CDM,302,RC,86698,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HISTOPLASMA COMP FIXATION,3026051,CDM,302,RC,86698,CPT,,,,,,outpatient,facility,,,63,26.46,5.81,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,13.79,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,14.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,13.79,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.62,,,fee schedule,,,12.25,,,fee schedule,,,12.25,,,fee schedule,,,12.01,,,fee schedule,,,13.79,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,13.79,,,fee schedule,,,13.79,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB CHAGAS,3026077,CDM,302,RC,86753,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB CHAGAS,3026077,CDM,302,RC,86753,CPT,,,,,,outpatient,facility,,,62,26.04,10.78,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,12.39,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,12.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,12.39,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,17.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.73,,,fee schedule,,,11,,,fee schedule,,,11,,,fee schedule,,,10.78,,,fee schedule,,,12.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,12.39,,,fee schedule,,,12.39,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHAGAS RIPA,3026085,CDM,302,RC,86753,CPT,,,,,,inpatient,facility,,,38,15.96,32.3,36.48,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,,,,,,,34.2,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHAGAS RIPA,3026085,CDM,302,RC,86753,CPT,,,,,,outpatient,facility,,,38,15.96,10.26,36.48,,32.3,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,26.14,,,percent of total billed charges,,,25.57,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,12.39,,,fee schedule,,,33.06,,,percent of total billed charges,,,33.06,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,12.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.2,,,percent of total billed charges,,,12.39,,,fee schedule,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,17.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.73,,,fee schedule,,,11,,,fee schedule,,,11,,,fee schedule,,,10.78,,,fee schedule,,,12.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",29.68,,,percent of total billed charges,,,34.58,,,percent of total billed charges,,,12.39,,,fee schedule,,,12.39,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BACLOFEN,3026184,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,132,55.44,112.2,126.72,,112.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.84,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,126.72,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BACLOFEN,3026184,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,132,55.44,16.22,126.72,,112.2,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,90.82,,,percent of total billed charges,,,88.84,,,percent of total billed charges,,,111.54,,,percent of total billed charges,,,18.64,,,fee schedule,,,114.84,,,percent of total billed charges,,,114.84,,,percent of total billed charges,,,112.2,,,percent of total billed charges,,,126.72,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",118.8,,,percent of total billed charges,,,18.64,,,fee schedule,,,122.76,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",103.09,,,percent of total billed charges,,,120.12,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE ANLYS MUT C KIT,3026234,CDM,310,RC,81272,CPT,,,,,,inpatient,facility,,,1093,459.06,929.05,1049.28,,929.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,950.91,,,percent of total billed charges,,,,,,,,,983.7,,,percent of total billed charges,,,1049.28,,,percent of total billed charges,,,1038.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1016.49,,,percent of total billed charges,,,1038.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE ANLYS MUT C KIT,3026234,CDM,310,RC,81272,CPT,,,,,,outpatient,facility,,,1093,459.06,295.11,1093,,929.05,,,percent of total billed charges,,,295.11,,,percent of total billed charges,,,751.98,,,percent of total billed charges,,,735.59,,,percent of total billed charges,,,923.58,,,percent of total billed charges,,,329.51,,,fee schedule,,,950.91,,,percent of total billed charges,,,950.91,,,percent of total billed charges,,,929.05,,,percent of total billed charges,,,1049.28,,,percent of total billed charges,,,1038.35,,,percent of total billed charges,,,336.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",983.7,,,percent of total billed charges,,,329.51,,,fee schedule,,,1016.49,,,percent of total billed charges,,,1038.35,,,percent of total billed charges,,,477.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",444.84,,,fee schedule,,,1093,,,fee schedule,,,1093,,,fee schedule,,,1093,,,fee schedule,,,329.51,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",853.63,,,percent of total billed charges,,,994.63,,,percent of total billed charges,,,329.51,,,fee schedule,,,329.51,,,fee schedule,,,,,,,,
LAB THYROXINE T 4 ELUTION,3026473,CDM,301,RC,84437,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROXINE T 4 ELUTION,3026473,CDM,301,RC,84437,CPT,,,,,,outpatient,facility,,,20,8.4,5.4,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.47,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.47,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,5.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE BCR ABL1 REFLEX P210 NS,3026663,CDM,310,RC,81206,CPT,,,,,,inpatient,facility,,,492,206.64,418.2,472.32,,418.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.04,,,percent of total billed charges,,,,,,,,,442.8,,,percent of total billed charges,,,472.32,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,457.56,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BCR ABL1 REFLEX P210 NS,3026663,CDM,310,RC,81206,CPT,,,,,,outpatient,facility,,,492,206.64,132.84,492,,418.2,,,percent of total billed charges,,,132.84,,,percent of total billed charges,,,338.5,,,percent of total billed charges,,,331.12,,,percent of total billed charges,,,415.74,,,percent of total billed charges,,,163.96,,,fee schedule,,,428.04,,,percent of total billed charges,,,428.04,,,percent of total billed charges,,,418.2,,,percent of total billed charges,,,472.32,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,167.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",442.8,,,percent of total billed charges,,,163.96,,,fee schedule,,,457.56,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,237.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",221.35,,,fee schedule,,,492,,,fee schedule,,,492,,,fee schedule,,,492,,,fee schedule,,,163.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",384.25,,,percent of total billed charges,,,447.72,,,percent of total billed charges,,,163.96,,,fee schedule,,,163.96,,,fee schedule,,,143.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE EGFR VAR COMMON NS,3026671,CDM,310,RC,81235,CPT,,,,,,inpatient,facility,,,974,409.08,827.9,935.04,,827.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.38,,,percent of total billed charges,,,,,,,,,876.6,,,percent of total billed charges,,,935.04,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,905.82,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE EGFR VAR COMMON NS,3026671,CDM,310,RC,81235,CPT,,,,,,outpatient,facility,,,974,409.08,262.98,974,,827.9,,,percent of total billed charges,,,262.98,,,percent of total billed charges,,,670.11,,,percent of total billed charges,,,655.5,,,percent of total billed charges,,,823.03,,,percent of total billed charges,,,324.58,,,fee schedule,,,847.38,,,percent of total billed charges,,,847.38,,,percent of total billed charges,,,827.9,,,percent of total billed charges,,,935.04,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,331.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",876.6,,,percent of total billed charges,,,324.58,,,fee schedule,,,905.82,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,470.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",438.18,,,fee schedule,,,974,,,fee schedule,,,974,,,fee schedule,,,974,,,fee schedule,,,324.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",760.69,,,percent of total billed charges,,,886.34,,,percent of total billed charges,,,324.58,,,fee schedule,,,324.58,,,fee schedule,,,,,,,,
LAB IBD SGI DIAGNOSTIC,3026689,CDM,310,RC,81479,CPT,,,,,,inpatient,facility,,,292,122.64,248.2,280.32,,248.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.04,,,percent of total billed charges,,,,,,,,,262.8,,,percent of total billed charges,,,280.32,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,271.56,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IBD SGI DIAGNOSTIC,3026689,CDM,310,RC,81479,CPT,,,,,,outpatient,facility,,,292,122.64,78.84,292,,248.2,,,percent of total billed charges,,,78.84,,,percent of total billed charges,,,200.9,,,percent of total billed charges,,,196.52,,,percent of total billed charges,,,246.74,,,percent of total billed charges,,,,,,,,,254.04,,,percent of total billed charges,,,254.04,,,percent of total billed charges,,,248.2,,,percent of total billed charges,,,280.32,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,262.8,,,percent of total billed charges,,,,,,,,,271.56,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,,,,,,,292,,,fee schedule,,,292,,,fee schedule,,,286.16,,,fee schedule,,,,,,,,,228.05,,,percent of total billed charges,,,265.72,,,percent of total billed charges,,,,,,,,,,,,,,,204.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR HEMOGLOBIN UNSTABLE,3026994,CDM,301,RC,83068,CPT,,,,,,inpatient,facility,,,126,52.92,107.1,120.96,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.62,,,percent of total billed charges,,,,,,,,,113.4,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR HEMOGLOBIN UNSTABLE,3026994,CDM,301,RC,83068,CPT,,,,,,outpatient,facility,,,126,52.92,8.24,120.96,,107.1,,,percent of total billed charges,,,34.02,,,percent of total billed charges,,,86.69,,,percent of total billed charges,,,84.8,,,percent of total billed charges,,,106.47,,,percent of total billed charges,,,9.47,,,fee schedule,,,109.62,,,percent of total billed charges,,,109.62,,,percent of total billed charges,,,107.1,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,9.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",113.4,,,percent of total billed charges,,,9.47,,,fee schedule,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,13.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.78,,,fee schedule,,,8.41,,,fee schedule,,,8.41,,,fee schedule,,,8.24,,,fee schedule,,,9.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",98.41,,,percent of total billed charges,,,114.66,,,percent of total billed charges,,,9.47,,,fee schedule,,,9.47,,,fee schedule,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD NURSERY LEVEL 4,30270,CDM,174,RC,,,,,,,,inpatient,facility,,,9900,4158,8415,9900,,8415,,,percent of total billed charges,,,,,,,,,9900,,,case rate,,,9900,,,case rate,,,,,,,,,,,,,,,8613,,,percent of total billed charges,,,,,,,,,8910,,,percent of total billed charges,,,9504,,,percent of total billed charges,,,9405,,,percent of total billed charges,,,,,,,,,8910,,,percent of total billed charges,,,,,,,,,9207,,,percent of total billed charges,,,9405,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9900,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RNA NOROVIRUS AMP PROBE,3027018,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RNA NOROVIRUS AMP PROBE,3027018,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PRETREAT SERUM RBC AB DILUTION,3027554,CDM,302,RC,86976,CPT,,,,,,inpatient,facility,,,150,63,127.5,144,,127.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.5,,,percent of total billed charges,,,,,,,,,135,,,percent of total billed charges,,,144,,,percent of total billed charges,,,142.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,139.5,,,percent of total billed charges,,,142.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM RBC AB DILUTION,3027554,CDM,302,RC,86976,CPT,,,,,,outpatient,facility,,,150,63,29.77,144,,127.5,,,percent of total billed charges,,,40.5,,,percent of total billed charges,,,103.2,,,percent of total billed charges,,,100.95,,,percent of total billed charges,,,126.75,,,percent of total billed charges,,,,,,,,,130.5,,,percent of total billed charges,,,130.5,,,percent of total billed charges,,,127.5,,,percent of total billed charges,,,144,,,percent of total billed charges,,,142.5,,,percent of total billed charges,,,,,,,,,135,,,percent of total billed charges,,,,,,,,,139.5,,,percent of total billed charges,,,142.5,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,117.15,,,percent of total billed charges,,,136.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM RBC AB DILUTION,3027554,CDM,302,RC,86976,CPT,5731,APC,,,,outpatient,facility,,,150,150,13.56,44.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HIV 2 REV T ANDPRB AMP,3027612,CDM,306,RC,87538,CPT,,,,,,inpatient,facility,,,122,51.24,103.7,117.12,,103.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.14,,,percent of total billed charges,,,,,,,,,109.8,,,percent of total billed charges,,,117.12,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.46,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HIV 2 REV T ANDPRB AMP,3027612,CDM,306,RC,87538,CPT,,,,,,outpatient,facility,,,122,51.24,30.54,117.12,,103.7,,,percent of total billed charges,,,32.94,,,percent of total billed charges,,,83.94,,,percent of total billed charges,,,82.11,,,percent of total billed charges,,,103.09,,,percent of total billed charges,,,35.09,,,fee schedule,,,106.14,,,percent of total billed charges,,,106.14,,,percent of total billed charges,,,103.7,,,percent of total billed charges,,,117.12,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",109.8,,,percent of total billed charges,,,35.09,,,fee schedule,,,113.46,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",95.28,,,percent of total billed charges,,,111.02,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MICRODISSECTION LASER,3027729,CDM,312,RC,88380,CPT,,,,,,inpatient,facility,,,638,267.96,542.3,612.48,,542.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,555.06,,,percent of total billed charges,,,,,,,,,574.2,,,percent of total billed charges,,,612.48,,,percent of total billed charges,,,606.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,593.34,,,percent of total billed charges,,,606.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MICRODISSECTION LASER,3027729,CDM,312,RC,88380,CPT,,,,,,outpatient,facility,,,638,267.96,172.26,638,,542.3,,,percent of total billed charges,,,172.26,,,percent of total billed charges,,,438.94,,,percent of total billed charges,,,429.37,,,percent of total billed charges,,,539.11,,,percent of total billed charges,,,,,,,,,555.06,,,percent of total billed charges,,,555.06,,,percent of total billed charges,,,542.3,,,percent of total billed charges,,,612.48,,,percent of total billed charges,,,606.1,,,percent of total billed charges,,,,,,,,,574.2,,,percent of total billed charges,,,,,,,,,593.34,,,percent of total billed charges,,,606.1,,,percent of total billed charges,,,,,,,,,,,,,,,638,,,fee schedule,,,638,,,fee schedule,,,638,,,fee schedule,,,,,,,,,498.28,,,percent of total billed charges,,,580.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA RESP MLTPLX 12 25 TGT,3027752,CDM,306,RC,87633,CPT,,,,,,inpatient,facility,,,1251,525.42,1063.35,1200.96,,1063.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.37,,,percent of total billed charges,,,,,,,,,1125.9,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA RESP MLTPLX 12 25 TGT,3027752,CDM,306,RC,87633,CPT,,,,,,outpatient,facility,,,1251,525.42,337.77,1200.96,,1063.35,,,percent of total billed charges,,,337.77,,,percent of total billed charges,,,860.69,,,percent of total billed charges,,,841.92,,,percent of total billed charges,,,1057.1,,,percent of total billed charges,,,416.78,,,fee schedule,,,1088.37,,,percent of total billed charges,,,1088.37,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,425.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1125.9,,,percent of total billed charges,,,416.78,,,fee schedule,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,604.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.65,,,fee schedule,,,370.1,,,fee schedule,,,370.1,,,fee schedule,,,362.7,,,fee schedule,,,416.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",977.03,,,percent of total billed charges,,,1138.41,,,percent of total billed charges,,,416.78,,,fee schedule,,,416.78,,,fee schedule,,,502.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA MYCOPLAS PNEU PRB AMP,3027778,CDM,306,RC,87581,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MYCOPLAS PNEU PRB AMP,3027778,CDM,306,RC,87581,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CYTOMEGALOVIRUS NS,3027786,CDM,302,RC,86644,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CYTOMEGALOVIRUS NS,3027786,CDM,302,RC,86644,CPT,,,,,,outpatient,facility,,,56,23.52,12.52,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,14.39,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,14.39,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC GLUCOSE QN BLOOD,3027935,CDM,301,RC,82947,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GLUCOSE QN BLOOD,3027935,CDM,301,RC,82947,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,12,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.93,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.93,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OXCARBAZEPINE,3028024,CDM,301,RC,80183,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OXCARBAZEPINE,3028024,CDM,301,RC,80183,CPT,,,,,,outpatient,facility,,,69,28.98,11.53,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,13.25,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,13.25,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COPPER SERUM,3028164,CDM,301,RC,82525,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COPPER SERUM,3028164,CDM,301,RC,82525,CPT,,,,,,outpatient,facility,,,63,26.46,10.8,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,12.41,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,12.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,12.41,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,17.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.75,,,fee schedule,,,11.02,,,fee schedule,,,11.02,,,fee schedule,,,10.8,,,fee schedule,,,12.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,12.41,,,fee schedule,,,12.41,,,fee schedule,,,15.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ZINC,3028172,CDM,301,RC,84630,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ZINC,3028172,CDM,301,RC,84630,CPT,,,,,,outpatient,facility,,,61,25.62,9.91,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,11.39,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,11.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,11.39,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,16.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.38,,,fee schedule,,,10.11,,,fee schedule,,,10.11,,,fee schedule,,,9.91,,,fee schedule,,,11.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,11.39,,,fee schedule,,,11.39,,,fee schedule,,,13.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ITRACONAZOLE,3028230,CDM,301,RC,80189,CPT,,,,,,inpatient,facility,,,131,55.02,111.35,125.76,,111.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.97,,,percent of total billed charges,,,,,,,,,117.9,,,percent of total billed charges,,,125.76,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.83,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ITRACONAZOLE,3028230,CDM,301,RC,80189,CPT,,,,,,outpatient,facility,,,131,55.02,23.59,125.76,,111.35,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,90.13,,,percent of total billed charges,,,88.16,,,percent of total billed charges,,,110.69,,,percent of total billed charges,,,27.11,,,fee schedule,,,113.97,,,percent of total billed charges,,,113.97,,,percent of total billed charges,,,111.35,,,percent of total billed charges,,,125.76,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,27.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",117.9,,,percent of total billed charges,,,27.11,,,fee schedule,,,121.83,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,39.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.6,,,fee schedule,,,24.07,,,fee schedule,,,24.07,,,fee schedule,,,23.59,,,fee schedule,,,27.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",102.31,,,percent of total billed charges,,,119.21,,,percent of total billed charges,,,27.11,,,fee schedule,,,27.11,,,fee schedule,,,23.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE PDGFRA,3028313,CDM,310,RC,81314,CPT,,,,,,inpatient,facility,,,989,415.38,840.65,949.44,,840.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,860.43,,,percent of total billed charges,,,,,,,,,890.1,,,percent of total billed charges,,,949.44,,,percent of total billed charges,,,939.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,919.77,,,percent of total billed charges,,,939.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE PDGFRA,3028313,CDM,310,RC,81314,CPT,,,,,,outpatient,facility,,,989,415.38,267.03,989,,840.65,,,percent of total billed charges,,,267.03,,,percent of total billed charges,,,680.43,,,percent of total billed charges,,,665.6,,,percent of total billed charges,,,835.7,,,percent of total billed charges,,,329.51,,,fee schedule,,,860.43,,,percent of total billed charges,,,860.43,,,percent of total billed charges,,,840.65,,,percent of total billed charges,,,949.44,,,percent of total billed charges,,,939.55,,,percent of total billed charges,,,336.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",890.1,,,percent of total billed charges,,,329.51,,,fee schedule,,,919.77,,,percent of total billed charges,,,939.55,,,percent of total billed charges,,,477.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",444.84,,,fee schedule,,,989,,,fee schedule,,,989,,,fee schedule,,,989,,,fee schedule,,,329.51,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",772.41,,,percent of total billed charges,,,899.99,,,percent of total billed charges,,,329.51,,,fee schedule,,,329.51,,,fee schedule,,,,,,,,
LAB DET IA MUCORALES PCR PRB AMP,3028347,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,275,115.5,233.75,264,,233.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.25,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MUCORALES PCR PRB AMP,3028347,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,275,115.5,30.54,264,,233.75,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,189.2,,,percent of total billed charges,,,185.07,,,percent of total billed charges,,,232.38,,,percent of total billed charges,,,35.09,,,fee schedule,,,239.25,,,percent of total billed charges,,,239.25,,,percent of total billed charges,,,233.75,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",247.5,,,percent of total billed charges,,,35.09,,,fee schedule,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",214.78,,,percent of total billed charges,,,250.25,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA NORCARDIA PCR PRB AMP,3028354,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,362,152.04,307.7,347.52,,307.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,314.94,,,percent of total billed charges,,,,,,,,,325.8,,,percent of total billed charges,,,347.52,,,percent of total billed charges,,,343.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,336.66,,,percent of total billed charges,,,343.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA NORCARDIA PCR PRB AMP,3028354,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,362,152.04,30.54,347.52,,307.7,,,percent of total billed charges,,,97.74,,,percent of total billed charges,,,249.06,,,percent of total billed charges,,,243.63,,,percent of total billed charges,,,305.89,,,percent of total billed charges,,,35.09,,,fee schedule,,,314.94,,,percent of total billed charges,,,314.94,,,percent of total billed charges,,,307.7,,,percent of total billed charges,,,347.52,,,percent of total billed charges,,,343.9,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",325.8,,,percent of total billed charges,,,35.09,,,fee schedule,,,336.66,,,percent of total billed charges,,,343.9,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",282.72,,,percent of total billed charges,,,329.42,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA COV19 ANDFLU A ANDB PRB AMP,3028388,CDM,306,RC,87636,CPT,,,,,,inpatient,facility,,,428,179.76,363.8,410.88,,363.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.36,,,percent of total billed charges,,,,,,,,,385.2,,,percent of total billed charges,,,410.88,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.04,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA COV19 ANDFLU A ANDB PRB AMP,3028388,CDM,306,RC,87636,CPT,,,,,,outpatient,facility,,,428,179.76,115.56,410.88,,363.8,,,percent of total billed charges,,,115.56,,,percent of total billed charges,,,294.46,,,percent of total billed charges,,,288.04,,,percent of total billed charges,,,361.66,,,percent of total billed charges,,,142.63,,,fee schedule,,,372.36,,,percent of total billed charges,,,372.36,,,percent of total billed charges,,,363.8,,,percent of total billed charges,,,410.88,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,145.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",385.2,,,percent of total billed charges,,,142.63,,,fee schedule,,,398.04,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,206.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",192.55,,,fee schedule,,,126.66,,,fee schedule,,,126.66,,,fee schedule,,,124.13,,,fee schedule,,,142.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",334.27,,,percent of total billed charges,,,389.48,,,percent of total billed charges,,,142.63,,,fee schedule,,,142.63,,,fee schedule,,,142.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THIOPURINE,3028461,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,160,67.2,136,153.6,,136,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.2,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THIOPURINE,3028461,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,160,67.2,16.22,153.6,,136,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,110.08,,,percent of total billed charges,,,107.68,,,percent of total billed charges,,,135.2,,,percent of total billed charges,,,18.64,,,fee schedule,,,139.2,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,136,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",144,,,percent of total billed charges,,,18.64,,,fee schedule,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",124.96,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PATH GROSS ONLY LVL 1 NS,3028487,CDM,312,RC,88300,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ONLY LVL 1 NS,3028487,CDM,312,RC,88300,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ONLY LVL 1 NS,3028487,CDM,312,RC,88300,CPT,5731,APC,,,,outpatient,facility,,,75,75,13.56,44.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TISS NON NEO TMR SOLID NS,3028537,CDM,311,RC,88239,CPT,,,,,,inpatient,facility,,,443,186.06,376.55,425.28,,376.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,385.41,,,percent of total billed charges,,,,,,,,,398.7,,,percent of total billed charges,,,425.28,,,percent of total billed charges,,,420.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,411.99,,,percent of total billed charges,,,420.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TISS NON NEO TMR SOLID NS,3028537,CDM,311,RC,88239,CPT,,,,,,outpatient,facility,,,443,186.06,119.61,425.28,,376.55,,,percent of total billed charges,,,119.61,,,percent of total billed charges,,,304.78,,,percent of total billed charges,,,298.14,,,percent of total billed charges,,,374.33,,,percent of total billed charges,,,147.52,,,fee schedule,,,385.41,,,percent of total billed charges,,,385.41,,,percent of total billed charges,,,376.55,,,percent of total billed charges,,,425.28,,,percent of total billed charges,,,420.85,,,percent of total billed charges,,,150.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",398.7,,,percent of total billed charges,,,147.52,,,fee schedule,,,411.99,,,percent of total billed charges,,,420.85,,,percent of total billed charges,,,213.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",199.15,,,fee schedule,,,131,,,fee schedule,,,131,,,fee schedule,,,128.38,,,fee schedule,,,147.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",345.98,,,percent of total billed charges,,,403.13,,,percent of total billed charges,,,147.52,,,fee schedule,,,147.52,,,fee schedule,,,180.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ESTRADIOL TOTAL,3028669,CDM,301,RC,82670,CPT,,,,,,inpatient,facility,,,84,35.28,71.4,80.64,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.08,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ESTRADIOL TOTAL,3028669,CDM,301,RC,82670,CPT,,,,,,outpatient,facility,,,84,35.28,22.68,80.64,,71.4,,,percent of total billed charges,,,22.68,,,percent of total billed charges,,,57.79,,,percent of total billed charges,,,56.53,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,27.94,,,fee schedule,,,73.08,,,percent of total billed charges,,,73.08,,,percent of total billed charges,,,71.4,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,28.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",75.6,,,percent of total billed charges,,,27.94,,,fee schedule,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,40.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.72,,,fee schedule,,,24.81,,,fee schedule,,,24.81,,,fee schedule,,,24.31,,,fee schedule,,,27.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",65.6,,,percent of total billed charges,,,76.44,,,percent of total billed charges,,,27.94,,,fee schedule,,,27.94,,,fee schedule,,,34.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ESTRADIOL TOTAL NS,3028677,CDM,301,RC,82670,CPT,,,,,,inpatient,facility,,,84,35.28,71.4,80.64,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.08,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ESTRADIOL TOTAL NS,3028677,CDM,301,RC,82670,CPT,,,,,,outpatient,facility,,,84,35.28,22.68,80.64,,71.4,,,percent of total billed charges,,,22.68,,,percent of total billed charges,,,57.79,,,percent of total billed charges,,,56.53,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,27.94,,,fee schedule,,,73.08,,,percent of total billed charges,,,73.08,,,percent of total billed charges,,,71.4,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,28.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",75.6,,,percent of total billed charges,,,27.94,,,fee schedule,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,40.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.72,,,fee schedule,,,24.81,,,fee schedule,,,24.81,,,fee schedule,,,24.31,,,fee schedule,,,27.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",65.6,,,percent of total billed charges,,,76.44,,,percent of total billed charges,,,27.94,,,fee schedule,,,27.94,,,fee schedule,,,34.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARBAMAZEPINE  10 11 EPOXIDE,3028701,CDM,301,RC,80161,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARBAMAZEPINE  10 11 EPOXIDE,3028701,CDM,301,RC,80161,CPT,,,,,,outpatient,facility,,,58,24.36,15.66,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,18.64,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,18.64,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARBAMAZEPINE  10 11 EPOXIDE NS,3028719,CDM,301,RC,80161,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARBAMAZEPINE  10 11 EPOXIDE NS,3028719,CDM,301,RC,80161,CPT,,,,,,outpatient,facility,,,90,37.8,16.22,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,18.64,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,18.64,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB QL SEMI QN SGL COVID 19,3028727,CDM,302,RC,86328,CPT,,,,,,inpatient,facility,,,136,57.12,115.6,130.56,,115.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.32,,,percent of total billed charges,,,,,,,,,122.4,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB QL SEMI QN SGL COVID 19,3028727,CDM,302,RC,86328,CPT,,,,,,outpatient,facility,,,136,57.12,36.72,130.56,,115.6,,,percent of total billed charges,,,36.72,,,percent of total billed charges,,,93.57,,,percent of total billed charges,,,91.53,,,percent of total billed charges,,,114.92,,,percent of total billed charges,,,45.28,,,fee schedule,,,118.32,,,percent of total billed charges,,,118.32,,,percent of total billed charges,,,115.6,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,46.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",122.4,,,percent of total billed charges,,,45.28,,,fee schedule,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,65.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.13,,,fee schedule,,,40.21,,,fee schedule,,,40.21,,,fee schedule,,,39.41,,,fee schedule,,,45.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",106.22,,,percent of total billed charges,,,123.76,,,percent of total billed charges,,,45.28,,,fee schedule,,,45.28,,,fee schedule,,,44.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE NUDT15 ANDTPMT VAR COMMON,3028735,CDM,310,RC,0169U,CPT,,,,,,inpatient,facility,,,1399,587.58,1189.15,1343.04,,1189.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1217.13,,,percent of total billed charges,,,,,,,,,1259.1,,,percent of total billed charges,,,1343.04,,,percent of total billed charges,,,1329.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1301.07,,,percent of total billed charges,,,1329.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE NUDT15 ANDTPMT VAR COMMON,3028735,CDM,310,RC,0169U,CPT,,,,,,outpatient,facility,,,1399,587.58,377.73,1399,,1189.15,,,percent of total billed charges,,,377.73,,,percent of total billed charges,,,962.51,,,percent of total billed charges,,,941.53,,,percent of total billed charges,,,1182.15,,,percent of total billed charges,,,466.17,,,fee schedule,,,1217.13,,,percent of total billed charges,,,1217.13,,,percent of total billed charges,,,1189.15,,,percent of total billed charges,,,1343.04,,,percent of total billed charges,,,1329.05,,,percent of total billed charges,,,475.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1259.1,,,percent of total billed charges,,,466.17,,,fee schedule,,,1301.07,,,percent of total billed charges,,,1329.05,,,percent of total billed charges,,,675.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",629.33,,,fee schedule,,,1399,,,fee schedule,,,1399,,,fee schedule,,,1399,,,fee schedule,,,466.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1092.62,,,percent of total billed charges,,,1273.09,,,percent of total billed charges,,,466.17,,,fee schedule,,,466.17,,,fee schedule,,,,,,,,
LAB IMM AB BP180 QN,3028768,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB BP180 QN,3028768,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,73,30.66,15.03,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,17.27,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,17.27,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ETOH BIOMRK TIS CORD 1 2,3028842,CDM,301,RC,80321,CPT,,,,,,inpatient,facility,,,110,46.2,93.5,105.6,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.7,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ETOH BIOMRK TIS CORD 1 2,3028842,CDM,301,RC,80321,CPT,,,,,,outpatient,facility,,,110,46.2,29.7,110,,93.5,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,75.68,,,percent of total billed charges,,,74.03,,,percent of total billed charges,,,92.95,,,percent of total billed charges,,,,,,,,,95.7,,,percent of total billed charges,,,95.7,,,percent of total billed charges,,,93.5,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,,,,,,,102.3,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,,,,,,,,,,,,,110,,,fee schedule,,,110,,,fee schedule,,,110,,,fee schedule,,,,,,,,,85.91,,,percent of total billed charges,,,100.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB IMM ELASTASE PANCREATIC QN,3028859,CDM,301,RC,82653,CPT,,,,,,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM ELASTASE PANCREATIC QN,3028859,CDM,301,RC,82653,CPT,,,,,,outpatient,facility,,,100,42,19.99,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,22.97,,,fee schedule,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,23.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90,,,percent of total billed charges,,,22.97,,,fee schedule,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,33.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.01,,,fee schedule,,,20.4,,,fee schedule,,,20.4,,,fee schedule,,,19.99,,,fee schedule,,,22.97,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,22.97,,,fee schedule,,,22.97,,,fee schedule,,,,,,,,
LAB SCR AB PHOSPHOLIPAS A2 RECPT FL,3029121,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,190,79.8,161.5,182.4,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.3,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB PHOSPHOLIPAS A2 RECPT FL,3029121,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,190,79.8,10.49,182.4,,161.5,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,130.72,,,percent of total billed charges,,,127.87,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,12.05,,,fee schedule,,,165.3,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",171,,,percent of total billed charges,,,12.05,,,fee schedule,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",148.39,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER PHOSPHOLPS A2 RECPT,3029139,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,285,119.7,242.25,273.6,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.95,,,percent of total billed charges,,,,,,,,,256.5,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.05,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER PHOSPHOLPS A2 RECPT,3029139,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,285,119.7,10.49,273.6,,242.25,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,196.08,,,percent of total billed charges,,,191.8,,,percent of total billed charges,,,240.82,,,percent of total billed charges,,,12.05,,,fee schedule,,,247.95,,,percent of total billed charges,,,247.95,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",256.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,265.05,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",222.59,,,percent of total billed charges,,,259.35,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DIS INFCT DNA PLASMA NGS UNTGT,3029147,CDM,310,RC,0152U,CPT,,,,,,inpatient,facility,,,6379,2679.18,5422.15,6123.84,,5422.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5549.73,,,percent of total billed charges,,,,,,,,,5741.1,,,percent of total billed charges,,,6123.84,,,percent of total billed charges,,,6060.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5932.47,,,percent of total billed charges,,,6060.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIS INFCT DNA PLASMA NGS UNTGT,3029147,CDM,310,RC,0152U,CPT,,,,,,outpatient,facility,,,6379,2679.18,1722.33,6379,,5422.15,,,percent of total billed charges,,,1722.33,,,percent of total billed charges,,,4388.75,,,percent of total billed charges,,,4293.07,,,percent of total billed charges,,,5390.26,,,percent of total billed charges,,,2126.2,,,fee schedule,,,5549.73,,,percent of total billed charges,,,5549.73,,,percent of total billed charges,,,5422.15,,,percent of total billed charges,,,6123.84,,,percent of total billed charges,,,6060.05,,,percent of total billed charges,,,2168.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5741.1,,,percent of total billed charges,,,2126.2,,,fee schedule,,,5932.47,,,percent of total billed charges,,,6060.05,,,percent of total billed charges,,,3082.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2870.37,,,fee schedule,,,6379,,,fee schedule,,,6379,,,fee schedule,,,6379,,,fee schedule,,,2126.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",4982,,,percent of total billed charges,,,5804.89,,,percent of total billed charges,,,2126.2,,,fee schedule,,,2126.2,,,fee schedule,,,,,,,,
LAB CROSS LINKS DEOXYPYRIDINOLINE,3029162,CDM,301,RC,82523,CPT,,,,,,inpatient,facility,,,113,47.46,96.05,108.48,,96.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,98.31,,,percent of total billed charges,,,,,,,,,101.7,,,percent of total billed charges,,,108.48,,,percent of total billed charges,,,107.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,105.09,,,percent of total billed charges,,,107.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CROSS LINKS DEOXYPYRIDINOLINE,3029162,CDM,301,RC,82523,CPT,,,,,,outpatient,facility,,,113,47.46,16.26,108.48,,96.05,,,percent of total billed charges,,,30.51,,,percent of total billed charges,,,77.74,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,95.48,,,percent of total billed charges,,,18.68,,,fee schedule,,,98.31,,,percent of total billed charges,,,98.31,,,percent of total billed charges,,,96.05,,,percent of total billed charges,,,108.48,,,percent of total billed charges,,,107.35,,,percent of total billed charges,,,19.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",101.7,,,percent of total billed charges,,,18.68,,,fee schedule,,,105.09,,,percent of total billed charges,,,107.35,,,percent of total billed charges,,,27.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.22,,,fee schedule,,,16.59,,,fee schedule,,,16.59,,,fee schedule,,,16.26,,,fee schedule,,,18.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",88.25,,,percent of total billed charges,,,102.83,,,percent of total billed charges,,,18.68,,,fee schedule,,,18.68,,,fee schedule,,,22.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ECHINOCOCCUS,3029170,CDM,302,RC,86682,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ECHINOCOCCUS,3029170,CDM,302,RC,86682,CPT,,,,,,outpatient,facility,,,71,29.82,11.32,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,13.01,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,13.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,13.01,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,18.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.56,,,fee schedule,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,11.32,,,fee schedule,,,13.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,13.01,,,fee schedule,,,13.01,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF SULFONAMIDES DAY 1 3,3029188,CDM,301,RC,80375,CPT,,,,,,inpatient,facility,,,147,61.74,124.95,141.12,,124.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.89,,,percent of total billed charges,,,,,,,,,132.3,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.71,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF SULFONAMIDES DAY 1 3,3029188,CDM,301,RC,80375,CPT,,,,,,outpatient,facility,,,147,61.74,16.89,147,,124.95,,,percent of total billed charges,,,39.69,,,percent of total billed charges,,,101.14,,,percent of total billed charges,,,98.93,,,percent of total billed charges,,,124.21,,,percent of total billed charges,,,,,,,,,127.89,,,percent of total billed charges,,,127.89,,,percent of total billed charges,,,124.95,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,132.3,,,percent of total billed charges,,,,,,,,,136.71,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,,,,,,,147,,,fee schedule,,,147,,,fee schedule,,,147,,,fee schedule,,,,,,,,,114.81,,,percent of total billed charges,,,133.77,,,percent of total billed charges,,,,,,,,,,,,,,,16.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID PHOSPHATASE TOTAL NS,3029196,CDM,301,RC,84060,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID PHOSPHATASE TOTAL NS,3029196,CDM,301,RC,84060,CPT,,,,,,outpatient,facility,,,63,26.46,6.64,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,7.64,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,7.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,7.64,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,11.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.31,,,fee schedule,,,6.78,,,fee schedule,,,6.78,,,fee schedule,,,6.64,,,fee schedule,,,7.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,7.64,,,fee schedule,,,7.64,,,fee schedule,,,9.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA VARICELLA ZOSTER PRB AMP,3029295,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA VARICELLA ZOSTER PRB AMP,3029295,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA ASPERGILLUS PCR PRB AMP,3029402,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,375,157.5,318.75,360,,318.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,326.25,,,percent of total billed charges,,,,,,,,,337.5,,,percent of total billed charges,,,360,,,percent of total billed charges,,,356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,348.75,,,percent of total billed charges,,,356.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA ASPERGILLUS PCR PRB AMP,3029402,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,375,157.5,30.54,360,,318.75,,,percent of total billed charges,,,101.25,,,percent of total billed charges,,,258,,,percent of total billed charges,,,252.37,,,percent of total billed charges,,,316.88,,,percent of total billed charges,,,35.09,,,fee schedule,,,326.25,,,percent of total billed charges,,,326.25,,,percent of total billed charges,,,318.75,,,percent of total billed charges,,,360,,,percent of total billed charges,,,356.25,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.5,,,percent of total billed charges,,,35.09,,,fee schedule,,,348.75,,,percent of total billed charges,,,356.25,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",292.87,,,percent of total billed charges,,,341.25,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM ALZHEIMER EVALUATION,3029428,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,351,147.42,298.35,336.96,,298.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,305.37,,,percent of total billed charges,,,,,,,,,315.9,,,percent of total billed charges,,,336.96,,,percent of total billed charges,,,333.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,326.43,,,percent of total billed charges,,,333.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM ALZHEIMER EVALUATION,3029428,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,351,147.42,15.03,336.96,,298.35,,,percent of total billed charges,,,94.77,,,percent of total billed charges,,,241.49,,,percent of total billed charges,,,236.22,,,percent of total billed charges,,,296.59,,,percent of total billed charges,,,17.27,,,fee schedule,,,305.37,,,percent of total billed charges,,,305.37,,,percent of total billed charges,,,298.35,,,percent of total billed charges,,,336.96,,,percent of total billed charges,,,333.45,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",315.9,,,percent of total billed charges,,,17.27,,,fee schedule,,,326.43,,,percent of total billed charges,,,333.45,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",274.13,,,percent of total billed charges,,,319.41,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRNSPL DNA DNR DRV CELL FREE QN,3029451,CDM,310,RC,0118U,CPT,,,,,,inpatient,facility,,,8260,3469.2,7021,7929.6,,7021,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7186.2,,,percent of total billed charges,,,,,,,,,7434,,,percent of total billed charges,,,7929.6,,,percent of total billed charges,,,7847,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7681.8,,,percent of total billed charges,,,7847,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRNSPL DNA DNR DRV CELL FREE QN,3029451,CDM,310,RC,0118U,CPT,,,,,,outpatient,facility,,,8260,3469.2,2230.2,8260,,7021,,,percent of total billed charges,,,2230.2,,,percent of total billed charges,,,5682.88,,,percent of total billed charges,,,5558.98,,,percent of total billed charges,,,6979.7,,,percent of total billed charges,,,2753.25,,,fee schedule,,,7186.2,,,percent of total billed charges,,,7186.2,,,percent of total billed charges,,,7021,,,percent of total billed charges,,,7929.6,,,percent of total billed charges,,,7847,,,percent of total billed charges,,,2808.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7434,,,percent of total billed charges,,,2753.25,,,fee schedule,,,7681.8,,,percent of total billed charges,,,7847,,,percent of total billed charges,,,3992.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3716.89,,,fee schedule,,,8260,,,fee schedule,,,8260,,,fee schedule,,,8260,,,fee schedule,,,2753.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6451.06,,,percent of total billed charges,,,7516.6,,,percent of total billed charges,,,2753.25,,,fee schedule,,,2753.25,,,fee schedule,,,,,,,,
LAB DRG SC INST ALYZ MECON DAY,3029477,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ MECON DAY,3029477,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD OCCULT FECES 1 3 IMM NS,3029519,CDM,301,RC,82274,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD OCCULT FECES 1 3 IMM NS,3029519,CDM,301,RC,82274,CPT,,,,,,outpatient,facility,,,62,26.04,13.86,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,15.92,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,16.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,15.92,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,23.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.49,,,fee schedule,,,14.14,,,fee schedule,,,14.14,,,fee schedule,,,13.86,,,fee schedule,,,15.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,19.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD PEDIATRICS PVT,30296,CDM,113,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT FRCTN ELECTRO ANDQN SERUM NS,3029642,CDM,301,RC,84165,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT FRCTN ELECTRO ANDQN SERUM NS,3029642,CDM,301,RC,84165,CPT,,,,,,outpatient,facility,,,56,23.52,9.35,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,10.74,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,10.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,10.74,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,15.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.5,,,fee schedule,,,9.54,,,fee schedule,,,9.54,,,fee schedule,,,9.35,,,fee schedule,,,10.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,10.74,,,fee schedule,,,10.74,,,fee schedule,,,13.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ SEMI QN,3029733,CDM,306,RC,87449,CPT,,,,,,inpatient,facility,,,147,61.74,124.95,141.12,,124.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,127.89,,,percent of total billed charges,,,,,,,,,132.3,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,136.71,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ SEMI QN,3029733,CDM,306,RC,87449,CPT,,,,,,outpatient,facility,,,147,61.74,10.43,141.12,,124.95,,,percent of total billed charges,,,39.69,,,percent of total billed charges,,,101.14,,,percent of total billed charges,,,98.93,,,percent of total billed charges,,,124.21,,,percent of total billed charges,,,11.98,,,fee schedule,,,127.89,,,percent of total billed charges,,,127.89,,,percent of total billed charges,,,124.95,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",132.3,,,percent of total billed charges,,,11.98,,,fee schedule,,,136.71,,,percent of total billed charges,,,139.65,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",114.81,,,percent of total billed charges,,,133.77,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE ATXN1 DET ALLELES ABNORMAL,3029790,CDM,310,RC,81178,CPT,,,,,,inpatient,facility,,,625,262.5,531.25,600,,531.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,543.75,,,percent of total billed charges,,,,,,,,,562.5,,,percent of total billed charges,,,600,,,percent of total billed charges,,,593.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,581.25,,,percent of total billed charges,,,593.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE ATXN1 DET ALLELES ABNORMAL,3029790,CDM,310,RC,81178,CPT,,,,,,outpatient,facility,,,625,262.5,137,625,,531.25,,,percent of total billed charges,,,168.75,,,percent of total billed charges,,,430,,,percent of total billed charges,,,420.62,,,percent of total billed charges,,,528.13,,,percent of total billed charges,,,137,,,fee schedule,,,543.75,,,percent of total billed charges,,,543.75,,,percent of total billed charges,,,531.25,,,percent of total billed charges,,,600,,,percent of total billed charges,,,593.75,,,percent of total billed charges,,,139.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.5,,,percent of total billed charges,,,137,,,fee schedule,,,581.25,,,percent of total billed charges,,,593.75,,,percent of total billed charges,,,198.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",184.95,,,fee schedule,,,625,,,fee schedule,,,625,,,fee schedule,,,625,,,fee schedule,,,137,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",488.13,,,percent of total billed charges,,,568.75,,,percent of total billed charges,,,137,,,fee schedule,,,137,,,fee schedule,,,,,,,,
LAB GENE ATXN3 DET ALLELES ABNORMAL,3029808,CDM,310,RC,81180,CPT,,,,,,inpatient,facility,,,640,268.8,544,614.4,,544,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,556.8,,,percent of total billed charges,,,,,,,,,576,,,percent of total billed charges,,,614.4,,,percent of total billed charges,,,608,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,595.2,,,percent of total billed charges,,,608,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE ATXN3 DET ALLELES ABNORMAL,3029808,CDM,310,RC,81180,CPT,,,,,,outpatient,facility,,,640,268.8,137,640,,544,,,percent of total billed charges,,,172.8,,,percent of total billed charges,,,440.32,,,percent of total billed charges,,,430.72,,,percent of total billed charges,,,540.8,,,percent of total billed charges,,,137,,,fee schedule,,,556.8,,,percent of total billed charges,,,556.8,,,percent of total billed charges,,,544,,,percent of total billed charges,,,614.4,,,percent of total billed charges,,,608,,,percent of total billed charges,,,139.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",576,,,percent of total billed charges,,,137,,,fee schedule,,,595.2,,,percent of total billed charges,,,608,,,percent of total billed charges,,,198.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",184.95,,,fee schedule,,,640,,,fee schedule,,,640,,,fee schedule,,,640,,,fee schedule,,,137,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",499.84,,,percent of total billed charges,,,582.4,,,percent of total billed charges,,,137,,,fee schedule,,,137,,,fee schedule,,,,,,,,
LAB GENE CACNA1A DET ALLELES ABNORM,3029816,CDM,310,RC,81184,CPT,,,,,,inpatient,facility,,,650,273,552.5,624,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.5,,,percent of total billed charges,,,,,,,,,585,,,percent of total billed charges,,,624,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,604.5,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CACNA1A DET ALLELES ABNORM,3029816,CDM,310,RC,81184,CPT,,,,,,outpatient,facility,,,650,273,137,650,,552.5,,,percent of total billed charges,,,175.5,,,percent of total billed charges,,,447.2,,,percent of total billed charges,,,437.45,,,percent of total billed charges,,,549.25,,,percent of total billed charges,,,137,,,fee schedule,,,565.5,,,percent of total billed charges,,,565.5,,,percent of total billed charges,,,552.5,,,percent of total billed charges,,,624,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,139.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",585,,,percent of total billed charges,,,137,,,fee schedule,,,604.5,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,198.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",184.95,,,fee schedule,,,650,,,fee schedule,,,650,,,fee schedule,,,650,,,fee schedule,,,137,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",507.65,,,percent of total billed charges,,,591.5,,,percent of total billed charges,,,137,,,fee schedule,,,137,,,fee schedule,,,,,,,,
LAB GENE FXN DET ALLELES ABNORMAL,3029824,CDM,310,RC,81284,CPT,,,,,,inpatient,facility,,,465,195.3,395.25,446.4,,395.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,404.55,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,446.4,,,percent of total billed charges,,,441.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,432.45,,,percent of total billed charges,,,441.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE FXN DET ALLELES ABNORMAL,3029824,CDM,310,RC,81284,CPT,,,,,,outpatient,facility,,,465,195.3,125.55,465,,395.25,,,percent of total billed charges,,,125.55,,,percent of total billed charges,,,319.92,,,percent of total billed charges,,,312.94,,,percent of total billed charges,,,392.93,,,percent of total billed charges,,,137,,,fee schedule,,,404.55,,,percent of total billed charges,,,404.55,,,percent of total billed charges,,,395.25,,,percent of total billed charges,,,446.4,,,percent of total billed charges,,,441.75,,,percent of total billed charges,,,139.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",418.5,,,percent of total billed charges,,,137,,,fee schedule,,,432.45,,,percent of total billed charges,,,441.75,,,percent of total billed charges,,,198.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",184.95,,,fee schedule,,,465,,,fee schedule,,,465,,,fee schedule,,,465,,,fee schedule,,,137,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",363.17,,,percent of total billed charges,,,423.15,,,percent of total billed charges,,,137,,,fee schedule,,,137,,,fee schedule,,,,,,,,
LAB AB ENA MYOSITIS,3029865,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA MYOSITIS,3029865,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,77,32.34,15.6,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,17.93,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,17.93,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT WB W INTRP ID MYOSITIS,3029873,CDM,301,RC,84182,CPT,,,,,,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT WB W INTRP ID MYOSITIS,3029873,CDM,301,RC,84182,CPT,,,,,,outpatient,facility,,,88,36.96,22.06,84.48,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,29.21,,,fee schedule,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,29.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",79.2,,,percent of total billed charges,,,29.21,,,fee schedule,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,42.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.43,,,fee schedule,,,25.94,,,fee schedule,,,25.94,,,fee schedule,,,25.42,,,fee schedule,,,29.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,29.21,,,fee schedule,,,29.21,,,fee schedule,,,22.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HLA CLASS I PHENOTYPE QL NS,3029907,CDM,302,RC,86830,CPT,,,,,,inpatient,facility,,,287,120.54,243.95,275.52,,243.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.69,,,percent of total billed charges,,,,,,,,,258.3,,,percent of total billed charges,,,275.52,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.91,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HLA CLASS I PHENOTYPE QL NS,3029907,CDM,302,RC,86830,CPT,,,,,,outpatient,facility,,,287,120.54,77.49,275.52,,243.95,,,percent of total billed charges,,,77.49,,,percent of total billed charges,,,197.46,,,percent of total billed charges,,,193.15,,,percent of total billed charges,,,242.51,,,percent of total billed charges,,,95.52,,,fee schedule,,,249.69,,,percent of total billed charges,,,249.69,,,percent of total billed charges,,,243.95,,,percent of total billed charges,,,275.52,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,97.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",258.3,,,percent of total billed charges,,,95.52,,,fee schedule,,,266.91,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,138.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",128.95,,,fee schedule,,,84.82,,,fee schedule,,,84.82,,,fee schedule,,,83.12,,,fee schedule,,,95.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",224.15,,,percent of total billed charges,,,261.17,,,percent of total billed charges,,,95.52,,,fee schedule,,,95.52,,,fee schedule,,,97.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMMUNOFIXATION EP TRANSFRN BETA,3029923,CDM,302,RC,86335,CPT,,,,,,inpatient,facility,,,89,37.38,75.65,85.44,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,,,,,,,80.1,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMMUNOFIXATION EP TRANSFRN BETA,3029923,CDM,302,RC,86335,CPT,,,,,,outpatient,facility,,,89,37.38,24.03,85.44,,75.65,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,61.23,,,percent of total billed charges,,,59.9,,,percent of total billed charges,,,75.2,,,percent of total billed charges,,,29.35,,,fee schedule,,,77.43,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,75.65,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,29.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",80.1,,,percent of total billed charges,,,29.35,,,fee schedule,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,42.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.62,,,fee schedule,,,26.06,,,fee schedule,,,26.06,,,fee schedule,,,25.54,,,fee schedule,,,29.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",69.51,,,percent of total billed charges,,,80.99,,,percent of total billed charges,,,29.35,,,fee schedule,,,29.35,,,fee schedule,,,35.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE TYPING HLA 1 LR AG 1 EA NS,3029949,CDM,310,RC,81374,CPT,,,,,,inpatient,facility,,,223,93.66,189.55,214.08,,189.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.01,,,percent of total billed charges,,,,,,,,,200.7,,,percent of total billed charges,,,214.08,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.39,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 LR AG 1 EA NS,3029949,CDM,310,RC,81374,CPT,,,,,,outpatient,facility,,,223,93.66,60.21,214.08,,189.55,,,percent of total billed charges,,,60.21,,,percent of total billed charges,,,153.42,,,percent of total billed charges,,,150.08,,,percent of total billed charges,,,188.44,,,percent of total billed charges,,,74.33,,,fee schedule,,,194.01,,,percent of total billed charges,,,194.01,,,percent of total billed charges,,,189.55,,,percent of total billed charges,,,214.08,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,75.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",200.7,,,percent of total billed charges,,,74.33,,,fee schedule,,,207.39,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,107.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.35,,,fee schedule,,,66.01,,,fee schedule,,,66.01,,,fee schedule,,,64.69,,,fee schedule,,,74.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",174.16,,,percent of total billed charges,,,202.93,,,percent of total billed charges,,,74.33,,,fee schedule,,,74.33,,,fee schedule,,,,,,,,
LAB IMM AB LDL OXIDIZED,3029964,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB LDL OXIDIZED,3029964,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,100,42,15.03,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,17.27,,,fee schedule,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90,,,percent of total billed charges,,,17.27,,,fee schedule,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHAGAS IGG,3029998,CDM,302,RC,86753,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHAGAS IGG,3029998,CDM,302,RC,86753,CPT,,,,,,outpatient,facility,,,72,30.24,10.78,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,12.39,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,12.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,12.39,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,17.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.73,,,fee schedule,,,11,,,fee schedule,,,11,,,fee schedule,,,10.78,,,fee schedule,,,12.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,12.39,,,fee schedule,,,12.39,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS PHOSPHAT PROTHROMBIN NS,3030111,CDM,301,RC,83516,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS PHOSPHAT PROTHROMBIN NS,3030111,CDM,301,RC,83516,CPT,,,,,,outpatient,facility,,,59,24.78,10.04,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,11.53,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,11.53,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HORMONE ANTIMULLERIAN NS,3030152,CDM,301,RC,82166,CPT,,,,,,inpatient,facility,,,116,48.72,98.6,111.36,,98.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,104.4,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HORMONE ANTIMULLERIAN NS,3030152,CDM,301,RC,82166,CPT,,,,,,outpatient,facility,,,116,48.72,31.32,111.36,,98.6,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,79.81,,,percent of total billed charges,,,78.07,,,percent of total billed charges,,,98.02,,,percent of total billed charges,,,38.62,,,fee schedule,,,100.92,,,percent of total billed charges,,,100.92,,,percent of total billed charges,,,98.6,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,39.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",104.4,,,percent of total billed charges,,,38.62,,,fee schedule,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.14,,,fee schedule,,,34.29,,,fee schedule,,,34.29,,,fee schedule,,,33.6,,,fee schedule,,,38.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",90.6,,,percent of total billed charges,,,105.56,,,percent of total billed charges,,,38.62,,,fee schedule,,,38.62,,,fee schedule,,,,,,,,
LAB DET IA PLASMODIUM PCR PRB AMP,3030178,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,502,210.84,426.7,481.92,,426.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,436.74,,,percent of total billed charges,,,,,,,,,451.8,,,percent of total billed charges,,,481.92,,,percent of total billed charges,,,476.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,466.86,,,percent of total billed charges,,,476.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA PLASMODIUM PCR PRB AMP,3030178,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,502,210.84,30.54,481.92,,426.7,,,percent of total billed charges,,,135.54,,,percent of total billed charges,,,345.38,,,percent of total billed charges,,,337.85,,,percent of total billed charges,,,424.19,,,percent of total billed charges,,,35.09,,,fee schedule,,,436.74,,,percent of total billed charges,,,436.74,,,percent of total billed charges,,,426.7,,,percent of total billed charges,,,481.92,,,percent of total billed charges,,,476.9,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",451.8,,,percent of total billed charges,,,35.09,,,fee schedule,,,466.86,,,percent of total billed charges,,,476.9,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",392.06,,,percent of total billed charges,,,456.82,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR INCL BODIES PARAS MYO NS,3030186,CDM,306,RC,87207,CPT,,,,,,inpatient,facility,,,287,120.54,243.95,275.52,,243.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.69,,,percent of total billed charges,,,,,,,,,258.3,,,percent of total billed charges,,,275.52,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.91,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR INCL BODIES PARAS MYO NS,3030186,CDM,306,RC,87207,CPT,,,,,,outpatient,facility,,,287,120.54,5.21,275.52,,243.95,,,percent of total billed charges,,,77.49,,,percent of total billed charges,,,197.46,,,percent of total billed charges,,,193.15,,,percent of total billed charges,,,242.51,,,percent of total billed charges,,,5.99,,,fee schedule,,,249.69,,,percent of total billed charges,,,249.69,,,percent of total billed charges,,,243.95,,,percent of total billed charges,,,275.52,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,6.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",258.3,,,percent of total billed charges,,,5.99,,,fee schedule,,,266.91,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,8.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.09,,,fee schedule,,,5.32,,,fee schedule,,,5.32,,,fee schedule,,,5.21,,,fee schedule,,,5.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",224.15,,,percent of total billed charges,,,261.17,,,percent of total billed charges,,,5.99,,,fee schedule,,,5.99,,,fee schedule,,,5.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BIOTINIDASE SPEC EA,3031754,CDM,301,RC,82261,CPT,,,,,,inpatient,facility,,,112,47.04,95.2,107.52,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BIOTINIDASE SPEC EA,3031754,CDM,301,RC,82261,CPT,,,,,,outpatient,facility,,,112,47.04,5.84,107.52,,95.2,,,percent of total billed charges,,,30.24,,,percent of total billed charges,,,77.06,,,percent of total billed charges,,,75.38,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,16.87,,,fee schedule,,,97.44,,,percent of total billed charges,,,97.44,,,percent of total billed charges,,,95.2,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,17.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.8,,,percent of total billed charges,,,16.87,,,fee schedule,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,24.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.77,,,fee schedule,,,14.98,,,fee schedule,,,14.98,,,fee schedule,,,14.68,,,fee schedule,,,16.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",87.47,,,percent of total billed charges,,,101.92,,,percent of total billed charges,,,16.87,,,fee schedule,,,16.87,,,fee schedule,,,5.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENCYCLIDINE,3032208,CDM,301,RC,83992,CPT,,,,,,inpatient,facility,,,94,39.48,79.9,90.24,,79.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.78,,,percent of total billed charges,,,,,,,,,84.6,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENCYCLIDINE,3032208,CDM,301,RC,83992,CPT,,,,,,outpatient,facility,,,94,39.48,25.38,94,,79.9,,,percent of total billed charges,,,25.38,,,percent of total billed charges,,,64.67,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,79.43,,,percent of total billed charges,,,,,,,,,81.78,,,percent of total billed charges,,,81.78,,,percent of total billed charges,,,79.9,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,84.6,,,percent of total billed charges,,,,,,,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,56.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,94,,,fee schedule,,,94,,,fee schedule,,,94,,,fee schedule,,,94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",73.41,,,percent of total billed charges,,,85.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ROOM AND BOARD PEDIATRICS PVT,30619,CDM,113,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELL W DIFF FLUID BODY,3062015,CDM,300,RC,89051,CPT,,,,,,inpatient,facility,,,17,7.14,14.45,16.32,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.79,,,percent of total billed charges,,,,,,,,,15.3,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELL W DIFF FLUID BODY,3062015,CDM,300,RC,89051,CPT,,,,,,outpatient,facility,,,17,7.14,4.59,16.32,,14.45,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,5.6,,,fee schedule,,,14.79,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,5.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.3,,,percent of total billed charges,,,5.6,,,fee schedule,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,8.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.56,,,fee schedule,,,4.97,,,fee schedule,,,4.97,,,fee schedule,,,4.87,,,fee schedule,,,5.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",13.28,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,5.6,,,fee schedule,,,5.6,,,fee schedule,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT CELL FLUID BODY,3062023,CDM,300,RC,89050,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELL FLUID BODY,3062023,CDM,300,RC,89050,CPT,,,,,,outpatient,facility,,,15,6.3,2.9,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.72,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.72,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.37,,,fee schedule,,,4.19,,,fee schedule,,,4.19,,,fee schedule,,,4.11,,,fee schedule,,,4.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.72,,,fee schedule,,,4.72,,,fee schedule,,,2.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT CELL CSF,3062031,CDM,300,RC,89050,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELL CSF,3062031,CDM,300,RC,89050,CPT,,,,,,outpatient,facility,,,15,6.3,2.9,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.72,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.72,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.37,,,fee schedule,,,4.19,,,fee schedule,,,4.19,,,fee schedule,,,4.11,,,fee schedule,,,4.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.72,,,fee schedule,,,4.72,,,fee schedule,,,2.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT CELL W DIFF CSF,3062049,CDM,300,RC,89051,CPT,,,,,,inpatient,facility,,,17,7.14,14.45,16.32,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.79,,,percent of total billed charges,,,,,,,,,15.3,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELL W DIFF CSF,3062049,CDM,300,RC,89051,CPT,,,,,,outpatient,facility,,,17,7.14,4.59,16.32,,14.45,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,5.6,,,fee schedule,,,14.79,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,5.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.3,,,percent of total billed charges,,,5.6,,,fee schedule,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,8.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.56,,,fee schedule,,,4.97,,,fee schedule,,,4.97,,,fee schedule,,,4.87,,,fee schedule,,,5.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",13.28,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,5.6,,,fee schedule,,,5.6,,,fee schedule,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ID CRYSTAL MICROSCOPY LIGHT,3062056,CDM,300,RC,89060,CPT,,,,,,inpatient,facility,,,22,9.24,18.7,21.12,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ID CRYSTAL MICROSCOPY LIGHT,3062056,CDM,300,RC,89060,CPT,,,,,,outpatient,facility,,,22,9.24,5.94,21.12,,18.7,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,14.81,,,percent of total billed charges,,,18.59,,,percent of total billed charges,,,7.33,,,fee schedule,,,19.14,,,percent of total billed charges,,,19.14,,,percent of total billed charges,,,18.7,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,7.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.8,,,percent of total billed charges,,,7.33,,,fee schedule,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,10.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.9,,,fee schedule,,,6.51,,,fee schedule,,,6.51,,,fee schedule,,,6.38,,,fee schedule,,,7.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",17.18,,,percent of total billed charges,,,20.02,,,percent of total billed charges,,,7.33,,,fee schedule,,,7.33,,,fee schedule,,,8.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ASSESSMENT LEUKOCYTE FECAL,3062080,CDM,300,RC,89055,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ASSESSMENT LEUKOCYTE FECAL,3062080,CDM,300,RC,89055,CPT,,,,,,outpatient,facility,,,13,5.46,3.01,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.27,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.27,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SEMEN MOTILITY ANDCOUNT WO HUHNER,3062130,CDM,300,RC,89310,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SEMEN MOTILITY ANDCOUNT WO HUHNER,3062130,CDM,300,RC,89310,CPT,,,,,,outpatient,facility,,,26,10.92,7.02,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.61,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.61,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.62,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.61,,,fee schedule,,,8.61,,,fee schedule,,,10.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB STAIN FAT FECES URINE SPUTUM,3062189,CDM,300,RC,89125,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB STAIN FAT FECES URINE SPUTUM,3062189,CDM,300,RC,89125,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.88,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.88,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.94,,,fee schedule,,,5.22,,,fee schedule,,,5.22,,,fee schedule,,,5.12,,,fee schedule,,,5.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.88,,,fee schedule,,,5.88,,,fee schedule,,,5.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COLLECTION SWEAT IONTOPHORESIS,3062205,CDM,300,RC,89230,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COLLECTION SWEAT IONTOPHORESIS,3062205,CDM,300,RC,89230,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB COLLECTION SWEAT IONTOPHORESIS,3062205,CDM,300,RC,89230,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB KETONES ACETONE QN,3062288,CDM,301,RC,82010,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB KETONES ACETONE QN,3062288,CDM,301,RC,82010,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.17,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.17,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.03,,,fee schedule,,,7.25,,,fee schedule,,,7.25,,,fee schedule,,,7.11,,,fee schedule,,,8.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.17,,,fee schedule,,,8.17,,,fee schedule,,,10.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL HEPATITIS ACUTE,3062312,CDM,301,RC,80074,CPT,,,,,,inpatient,facility,,,143,60.06,121.55,137.28,,121.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.41,,,percent of total billed charges,,,,,,,,,128.7,,,percent of total billed charges,,,137.28,,,percent of total billed charges,,,135.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.99,,,percent of total billed charges,,,135.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL HEPATITIS ACUTE,3062312,CDM,301,RC,80074,CPT,,,,,,outpatient,facility,,,143,60.06,38.61,137.28,,121.55,,,percent of total billed charges,,,38.61,,,percent of total billed charges,,,98.38,,,percent of total billed charges,,,96.24,,,percent of total billed charges,,,120.83,,,percent of total billed charges,,,47.63,,,fee schedule,,,124.41,,,percent of total billed charges,,,124.41,,,percent of total billed charges,,,121.55,,,percent of total billed charges,,,137.28,,,percent of total billed charges,,,135.85,,,percent of total billed charges,,,48.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",128.7,,,percent of total billed charges,,,47.63,,,fee schedule,,,132.99,,,percent of total billed charges,,,135.85,,,percent of total billed charges,,,69.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.3,,,fee schedule,,,42.3,,,fee schedule,,,42.3,,,fee schedule,,,41.45,,,fee schedule,,,47.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",111.68,,,percent of total billed charges,,,130.13,,,percent of total billed charges,,,47.63,,,fee schedule,,,47.63,,,fee schedule,,,55.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HORMONE ADRENOCORTICOTROPIC,3062338,CDM,301,RC,82024,CPT,,,,,,inpatient,facility,,,116,48.72,98.6,111.36,,98.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,104.4,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HORMONE ADRENOCORTICOTROPIC,3062338,CDM,301,RC,82024,CPT,,,,,,outpatient,facility,,,116,48.72,31.32,111.36,,98.6,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,79.81,,,percent of total billed charges,,,78.07,,,percent of total billed charges,,,98.02,,,percent of total billed charges,,,38.62,,,fee schedule,,,100.92,,,percent of total billed charges,,,100.92,,,percent of total billed charges,,,98.6,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,39.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",104.4,,,percent of total billed charges,,,38.62,,,fee schedule,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.14,,,fee schedule,,,34.29,,,fee schedule,,,34.29,,,fee schedule,,,33.6,,,fee schedule,,,38.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",90.6,,,percent of total billed charges,,,105.56,,,percent of total billed charges,,,38.62,,,fee schedule,,,38.62,,,fee schedule,,,47.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALBUMIN SRM PLASMA BLD WHL,3062346,CDM,301,RC,82040,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALBUMIN SRM PLASMA BLD WHL,3062346,CDM,301,RC,82040,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.95,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,5.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.95,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,7.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.68,,,fee schedule,,,4.4,,,fee schedule,,,4.4,,,fee schedule,,,4.31,,,fee schedule,,,4.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,4.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALCOHOL BREATH,3062379,CDM,301,RC,82075,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALCOHOL BREATH,3062379,CDM,301,RC,82075,CPT,,,,,,outpatient,facility,,,90,37.8,13.28,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,30,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,30.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,30,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,43.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",40.5,,,fee schedule,,,26.64,,,fee schedule,,,26.64,,,fee schedule,,,26.11,,,fee schedule,,,30,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,30,,,fee schedule,,,30,,,fee schedule,,,13.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALDOLASE,3062387,CDM,301,RC,82085,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALDOLASE,3062387,CDM,301,RC,82085,CPT,,,,,,outpatient,facility,,,53,22.26,8.45,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,9.71,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,9.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,9.71,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,14.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.11,,,fee schedule,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,8.45,,,fee schedule,,,9.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,9.71,,,fee schedule,,,9.71,,,fee schedule,,,11.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALDOSTERONE NS,3062395,CDM,301,RC,82088,CPT,,,,,,inpatient,facility,,,123,51.66,104.55,118.08,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.01,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALDOSTERONE NS,3062395,CDM,301,RC,82088,CPT,,,,,,outpatient,facility,,,123,51.66,33.21,118.08,,104.55,,,percent of total billed charges,,,33.21,,,percent of total billed charges,,,84.62,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,103.94,,,percent of total billed charges,,,40.75,,,fee schedule,,,107.01,,,percent of total billed charges,,,107.01,,,percent of total billed charges,,,104.55,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,41.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",110.7,,,percent of total billed charges,,,40.75,,,fee schedule,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,59.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.01,,,fee schedule,,,36.19,,,fee schedule,,,36.19,,,fee schedule,,,35.47,,,fee schedule,,,40.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.06,,,percent of total billed charges,,,111.93,,,percent of total billed charges,,,40.75,,,fee schedule,,,40.75,,,fee schedule,,,49.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALDOSTERONE URINE,3062403,CDM,301,RC,82088,CPT,,,,,,inpatient,facility,,,123,51.66,104.55,118.08,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.01,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALDOSTERONE URINE,3062403,CDM,301,RC,82088,CPT,,,,,,outpatient,facility,,,123,51.66,33.21,118.08,,104.55,,,percent of total billed charges,,,33.21,,,percent of total billed charges,,,84.62,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,103.94,,,percent of total billed charges,,,40.75,,,fee schedule,,,107.01,,,percent of total billed charges,,,107.01,,,percent of total billed charges,,,104.55,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,41.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",110.7,,,percent of total billed charges,,,40.75,,,fee schedule,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,59.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.01,,,fee schedule,,,36.19,,,fee schedule,,,36.19,,,fee schedule,,,35.47,,,fee schedule,,,40.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.06,,,percent of total billed charges,,,111.93,,,percent of total billed charges,,,40.75,,,fee schedule,,,40.75,,,fee schedule,,,49.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AFP SERUM,3062429,CDM,301,RC,82105,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AFP SERUM,3062429,CDM,301,RC,82105,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.77,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.77,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.64,,,fee schedule,,,14.89,,,fee schedule,,,14.89,,,fee schedule,,,14.59,,,fee schedule,,,16.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.77,,,fee schedule,,,16.77,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALPHA 1 ANTITRYPSIN TOTAL NS,3062445,CDM,301,RC,82103,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALPHA 1 ANTITRYPSIN TOTAL NS,3062445,CDM,301,RC,82103,CPT,,,,,,outpatient,facility,,,59,24.78,11.69,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,13.44,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,13.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,13.44,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,19.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.14,,,fee schedule,,,11.93,,,fee schedule,,,11.93,,,fee schedule,,,11.69,,,fee schedule,,,13.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,13.44,,,fee schedule,,,13.44,,,fee schedule,,,16.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALPHA 1 ANTITRYPSIN PHENOTYPE,3062452,CDM,301,RC,82104,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALPHA 1 ANTITRYPSIN PHENOTYPE,3062452,CDM,301,RC,82104,CPT,,,,,,outpatient,facility,,,63,26.46,12.58,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,14.46,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,14.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,14.46,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,20.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.52,,,fee schedule,,,12.84,,,fee schedule,,,12.84,,,fee schedule,,,12.58,,,fee schedule,,,14.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,14.46,,,fee schedule,,,14.46,,,fee schedule,,,17.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRANSFERASE AMINO ALANINE,3062460,CDM,301,RC,84460,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERASE AMINO ALANINE,3062460,CDM,301,RC,84460,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.3,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.3,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.16,,,fee schedule,,,4.71,,,fee schedule,,,4.71,,,fee schedule,,,4.62,,,fee schedule,,,5.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.3,,,fee schedule,,,5.3,,,fee schedule,,,6.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALUMINUM,3062478,CDM,301,RC,82108,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALUMINUM,3062478,CDM,301,RC,82108,CPT,,,,,,outpatient,facility,,,77,32.34,20.79,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,25.48,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,25.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,25.48,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,36.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.4,,,fee schedule,,,22.63,,,fee schedule,,,22.63,,,fee schedule,,,22.18,,,fee schedule,,,25.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,25.48,,,fee schedule,,,25.48,,,fee schedule,,,31.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS AMINO SGL QN SPEC EA,3062536,CDM,301,RC,82131,CPT,,,,,,inpatient,facility,,,91,38.22,77.35,87.36,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.17,,,percent of total billed charges,,,,,,,,,81.9,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,84.63,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS AMINO SGL QN SPEC EA,3062536,CDM,301,RC,82131,CPT,,,,,,outpatient,facility,,,91,38.22,20,87.36,,77.35,,,percent of total billed charges,,,24.57,,,percent of total billed charges,,,62.61,,,percent of total billed charges,,,61.24,,,percent of total billed charges,,,76.89,,,percent of total billed charges,,,22.98,,,fee schedule,,,79.17,,,percent of total billed charges,,,79.17,,,percent of total billed charges,,,77.35,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,23.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81.9,,,percent of total billed charges,,,22.98,,,fee schedule,,,84.63,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,33.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.02,,,fee schedule,,,20.41,,,fee schedule,,,20.41,,,fee schedule,,,20,,,fee schedule,,,22.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",71.07,,,percent of total billed charges,,,82.81,,,percent of total billed charges,,,22.98,,,fee schedule,,,22.98,,,fee schedule,,,20.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS AMINO 6 PLUS QN SPEC EA,3062551,CDM,301,RC,82139,CPT,,,,,,inpatient,facility,,,141,59.22,119.85,135.36,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS AMINO 6 PLUS QN SPEC EA,3062551,CDM,301,RC,82139,CPT,,,,,,outpatient,facility,,,141,59.22,5.84,135.36,,119.85,,,percent of total billed charges,,,38.07,,,percent of total billed charges,,,97.01,,,percent of total billed charges,,,94.89,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,16.87,,,fee schedule,,,122.67,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,17.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",126.9,,,percent of total billed charges,,,16.87,,,fee schedule,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,24.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.77,,,fee schedule,,,14.98,,,fee schedule,,,14.98,,,fee schedule,,,14.68,,,fee schedule,,,16.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",110.12,,,percent of total billed charges,,,128.31,,,percent of total billed charges,,,16.87,,,fee schedule,,,16.87,,,fee schedule,,,5.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS AMINO 6 PLUS QN URINE SPEC EA,3062569,CDM,301,RC,82139,CPT,,,,,,inpatient,facility,,,141,59.22,119.85,135.36,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS AMINO 6 PLUS QN URINE SPEC EA,3062569,CDM,301,RC,82139,CPT,,,,,,outpatient,facility,,,141,59.22,5.84,135.36,,119.85,,,percent of total billed charges,,,38.07,,,percent of total billed charges,,,97.01,,,percent of total billed charges,,,94.89,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,16.87,,,fee schedule,,,122.67,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,17.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",126.9,,,percent of total billed charges,,,16.87,,,fee schedule,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,24.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.77,,,fee schedule,,,14.98,,,fee schedule,,,14.98,,,fee schedule,,,14.68,,,fee schedule,,,16.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",110.12,,,percent of total billed charges,,,128.31,,,percent of total billed charges,,,16.87,,,fee schedule,,,16.87,,,fee schedule,,,5.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID AMINOLEVULINIC DELTA URINE,3062585,CDM,301,RC,82135,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID AMINOLEVULINIC DELTA URINE,3062585,CDM,301,RC,82135,CPT,,,,,,outpatient,facility,,,75,31.5,14.32,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,16.45,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,16.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,16.45,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,23.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.21,,,fee schedule,,,14.61,,,fee schedule,,,14.61,,,fee schedule,,,14.32,,,fee schedule,,,16.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,16.45,,,fee schedule,,,16.45,,,fee schedule,,,20.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMIODARONE,3062593,CDM,301,RC,80151,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMIODARONE,3062593,CDM,301,RC,80151,CPT,,,,,,outpatient,facility,,,90,37.8,16.22,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,18.64,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,18.64,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMMONIA,3062619,CDM,301,RC,82140,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMMONIA,3062619,CDM,301,RC,82140,CPT,,,,,,outpatient,facility,,,44,18.48,11.88,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.57,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.57,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,21.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.67,,,fee schedule,,,12.94,,,fee schedule,,,12.94,,,fee schedule,,,12.68,,,fee schedule,,,14.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.57,,,fee schedule,,,14.57,,,fee schedule,,,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMYLASE,3062650,CDM,301,RC,82150,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMYLASE,3062650,CDM,301,RC,82150,CPT,,,,,,outpatient,facility,,,20,8.4,5.4,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.48,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.48,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.75,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.48,,,fee schedule,,,6.48,,,fee schedule,,,6.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMYLASE FLUID BODY,3062668,CDM,301,RC,82150,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMYLASE FLUID BODY,3062668,CDM,301,RC,82150,CPT,,,,,,outpatient,facility,,,52,21.84,5.64,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,6.48,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,6.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,6.48,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,9.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.75,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.48,,,fee schedule,,,6.48,,,fee schedule,,,6.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMYLASE TOTAL,3062676,CDM,301,RC,82150,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMYLASE TOTAL,3062676,CDM,301,RC,82150,CPT,,,,,,outpatient,facility,,,54,22.68,5.64,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,6.48,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,6.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,6.48,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,9.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.75,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,6.48,,,fee schedule,,,6.48,,,fee schedule,,,6.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMYLASE URINE,3062684,CDM,301,RC,82150,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMYLASE URINE,3062684,CDM,301,RC,82150,CPT,,,,,,outpatient,facility,,,53,22.26,5.64,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,6.48,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,6.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,6.48,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,9.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.75,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,6.48,,,fee schedule,,,6.48,,,fee schedule,,,6.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANDROSTENEDIONE,3062718,CDM,301,RC,82157,CPT,,,,,,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANDROSTENEDIONE,3062718,CDM,301,RC,82157,CPT,,,,,,outpatient,facility,,,88,36.96,23.76,84.48,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,29.28,,,fee schedule,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,29.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",79.2,,,percent of total billed charges,,,29.28,,,fee schedule,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,42.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.53,,,fee schedule,,,26,,,fee schedule,,,26,,,fee schedule,,,25.48,,,fee schedule,,,29.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,29.28,,,fee schedule,,,29.28,,,fee schedule,,,35.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANGIOTENSIN I CONVERTING ENZYME,3062734,CDM,301,RC,82164,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANGIOTENSIN I CONVERTING ENZYME,3062734,CDM,301,RC,82164,CPT,,,,,,outpatient,facility,,,61,25.62,12.7,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,14.6,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,14.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,14.6,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,21.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.71,,,fee schedule,,,12.96,,,fee schedule,,,12.96,,,fee schedule,,,12.7,,,fee schedule,,,14.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,14.6,,,fee schedule,,,14.6,,,fee schedule,,,17.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB APOLIPOPROTEIN EA,3062759,CDM,301,RC,82172,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB APOLIPOPROTEIN EA,3062759,CDM,301,RC,82172,CPT,,,,,,outpatient,facility,,,64,26.88,17.28,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,21.09,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,21.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,21.09,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,30.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.47,,,fee schedule,,,18.73,,,fee schedule,,,18.73,,,fee schedule,,,18.36,,,fee schedule,,,21.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,21.09,,,fee schedule,,,21.09,,,fee schedule,,,18.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB APOLIPOPROTEIN A1 EA,3062767,CDM,301,RC,82172,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB APOLIPOPROTEIN A1 EA,3062767,CDM,301,RC,82172,CPT,,,,,,outpatient,facility,,,77,32.34,18.36,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,21.09,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,21.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,21.09,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,30.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.47,,,fee schedule,,,18.73,,,fee schedule,,,18.73,,,fee schedule,,,18.36,,,fee schedule,,,21.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,21.09,,,fee schedule,,,21.09,,,fee schedule,,,18.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB APOLIPOPROTEIN B EA,3062775,CDM,301,RC,82172,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB APOLIPOPROTEIN B EA,3062775,CDM,301,RC,82172,CPT,,,,,,outpatient,facility,,,64,26.88,17.28,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,21.09,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,21.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,21.09,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,30.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.47,,,fee schedule,,,18.73,,,fee schedule,,,18.73,,,fee schedule,,,18.36,,,fee schedule,,,21.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,21.09,,,fee schedule,,,21.09,,,fee schedule,,,18.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ARSENIC BLOOD NS,3062783,CDM,301,RC,82175,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ARSENIC BLOOD NS,3062783,CDM,301,RC,82175,CPT,,,,,,outpatient,facility,,,63,26.46,16.51,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,18.97,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,19.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,18.97,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,27.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.61,,,fee schedule,,,16.85,,,fee schedule,,,16.85,,,fee schedule,,,16.51,,,fee schedule,,,18.97,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,18.97,,,fee schedule,,,18.97,,,fee schedule,,,23.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ARSENIC NON BLOOD,3062791,CDM,301,RC,82175,CPT,,,,,,inpatient,facility,,,95,39.9,80.75,91.2,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.65,,,percent of total billed charges,,,,,,,,,85.5,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.35,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ARSENIC NON BLOOD,3062791,CDM,301,RC,82175,CPT,,,,,,outpatient,facility,,,95,39.9,16.51,91.2,,80.75,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,65.36,,,percent of total billed charges,,,63.93,,,percent of total billed charges,,,80.27,,,percent of total billed charges,,,18.97,,,fee schedule,,,82.65,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,19.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",85.5,,,percent of total billed charges,,,18.97,,,fee schedule,,,88.35,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,27.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.61,,,fee schedule,,,16.85,,,fee schedule,,,16.85,,,fee schedule,,,16.51,,,fee schedule,,,18.97,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",74.19,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,18.97,,,fee schedule,,,18.97,,,fee schedule,,,23.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRANSFERASE AMINO ASPARTATE,3062809,CDM,301,RC,84450,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERASE AMINO ASPARTATE,3062809,CDM,301,RC,84450,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.18,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.18,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL METAB BASIC W CA TOTAL,3062866,CDM,301,RC,80048,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL METAB BASIC W CA TOTAL,3062866,CDM,301,RC,80048,CPT,,,,,,outpatient,facility,,,26,10.92,7.02,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.46,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.46,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.42,,,fee schedule,,,7.51,,,fee schedule,,,7.51,,,fee schedule,,,7.36,,,fee schedule,,,8.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.46,,,fee schedule,,,8.46,,,fee schedule,,,9.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MICROGLOBULIN BETA 2,3062882,CDM,301,RC,82232,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MICROGLOBULIN BETA 2,3062882,CDM,301,RC,82232,CPT,,,,,,outpatient,facility,,,58,24.36,14.08,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,16.18,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,16.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,16.18,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,23.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.84,,,fee schedule,,,14.37,,,fee schedule,,,14.37,,,fee schedule,,,14.08,,,fee schedule,,,16.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,16.18,,,fee schedule,,,16.18,,,fee schedule,,,19.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB KETONES BETA HYDROXYBUTYRATE QN,3062916,CDM,301,RC,82010,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB KETONES BETA HYDROXYBUTYRATE QN,3062916,CDM,301,RC,82010,CPT,,,,,,outpatient,facility,,,60,25.2,7.11,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,8.17,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,8.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,8.17,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,11.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.03,,,fee schedule,,,7.25,,,fee schedule,,,7.25,,,fee schedule,,,7.11,,,fee schedule,,,8.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,8.17,,,fee schedule,,,8.17,,,fee schedule,,,10.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS BILE TOTAL,3062932,CDM,301,RC,82239,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS BILE TOTAL,3062932,CDM,301,RC,82239,CPT,,,,,,outpatient,facility,,,63,26.46,9.24,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,17.12,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,17.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,17.12,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,24.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.11,,,fee schedule,,,15.2,,,fee schedule,,,15.2,,,fee schedule,,,14.9,,,fee schedule,,,17.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,17.12,,,fee schedule,,,17.12,,,fee schedule,,,9.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BILIRUBIN DIRECT,3062957,CDM,301,RC,82248,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BILIRUBIN DIRECT,3062957,CDM,301,RC,82248,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.02,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.02,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.78,,,fee schedule,,,4.46,,,fee schedule,,,4.46,,,fee schedule,,,4.37,,,fee schedule,,,5.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.02,,,fee schedule,,,5.02,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BILIRUBIN DIRECT FLUID BODY,3062965,CDM,301,RC,82248,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BILIRUBIN DIRECT FLUID BODY,3062965,CDM,301,RC,82248,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.02,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.02,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.78,,,fee schedule,,,4.46,,,fee schedule,,,4.46,,,fee schedule,,,4.37,,,fee schedule,,,5.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.02,,,fee schedule,,,5.02,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BILIRUBIN TOTAL,3062973,CDM,301,RC,82247,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BILIRUBIN TOTAL,3062973,CDM,301,RC,82247,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.02,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.02,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.78,,,fee schedule,,,4.46,,,fee schedule,,,4.46,,,fee schedule,,,4.37,,,fee schedule,,,5.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.02,,,fee schedule,,,5.02,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BILIRUBIN TOTAL FLUID BODY,3062981,CDM,301,RC,82247,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BILIRUBIN TOTAL FLUID BODY,3062981,CDM,301,RC,82247,CPT,,,,,,outpatient,facility,,,57,23.94,4.37,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,5.02,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,5.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,5.02,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,7.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.78,,,fee schedule,,,4.46,,,fee schedule,,,4.46,,,fee schedule,,,4.37,,,fee schedule,,,5.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,5.02,,,fee schedule,,,5.02,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GASES BLD ANY COMBO ARTERIAL,3063005,CDM,301,RC,82803,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GASES BLD ANY COMBO ARTERIAL,3063005,CDM,301,RC,82803,CPT,,,,,,outpatient,facility,,,79,33.18,21.33,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,26.07,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,26.07,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,37.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.19,,,fee schedule,,,23.15,,,fee schedule,,,23.15,,,fee schedule,,,22.69,,,fee schedule,,,26.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,26.07,,,fee schedule,,,26.07,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GASES BLD ANY COMBO W SAT O2,3063021,CDM,301,RC,82805,CPT,,,,,,inpatient,facility,,,237,99.54,201.45,227.52,,201.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.19,,,percent of total billed charges,,,,,,,,,213.3,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GASES BLD ANY COMBO W SAT O2,3063021,CDM,301,RC,82805,CPT,,,,,,outpatient,facility,,,237,99.54,34.8,227.52,,201.45,,,percent of total billed charges,,,63.99,,,percent of total billed charges,,,163.06,,,percent of total billed charges,,,159.5,,,percent of total billed charges,,,200.26,,,percent of total billed charges,,,78.77,,,fee schedule,,,206.19,,,percent of total billed charges,,,206.19,,,percent of total billed charges,,,201.45,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,80.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",213.3,,,percent of total billed charges,,,78.77,,,fee schedule,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,114.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",106.34,,,fee schedule,,,69.95,,,fee schedule,,,69.95,,,fee schedule,,,68.55,,,fee schedule,,,78.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",185.1,,,percent of total billed charges,,,215.67,,,percent of total billed charges,,,78.77,,,fee schedule,,,78.77,,,fee schedule,,,34.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GASES BLD SAT O2 ONLY,3063039,CDM,301,RC,82810,CPT,,,,,,inpatient,facility,,,98,41.16,83.3,94.08,,83.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.26,,,percent of total billed charges,,,,,,,,,88.2,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GASES BLD SAT O2 ONLY,3063039,CDM,301,RC,82810,CPT,,,,,,outpatient,facility,,,98,41.16,8.51,94.08,,83.3,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,67.42,,,percent of total billed charges,,,65.95,,,percent of total billed charges,,,82.81,,,percent of total billed charges,,,9.77,,,fee schedule,,,85.26,,,percent of total billed charges,,,85.26,,,percent of total billed charges,,,83.3,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,9.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.2,,,percent of total billed charges,,,9.77,,,fee schedule,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,14.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.19,,,fee schedule,,,8.68,,,fee schedule,,,8.68,,,fee schedule,,,8.51,,,fee schedule,,,9.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",76.54,,,percent of total billed charges,,,89.18,,,percent of total billed charges,,,9.77,,,fee schedule,,,9.77,,,fee schedule,,,10.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GASES BLD ANY COMBO VENOUS,3063047,CDM,301,RC,82803,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GASES BLD ANY COMBO VENOUS,3063047,CDM,301,RC,82803,CPT,,,,,,outpatient,facility,,,79,33.18,21.33,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,26.07,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,26.07,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,37.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.19,,,fee schedule,,,23.15,,,fee schedule,,,23.15,,,fee schedule,,,22.69,,,fee schedule,,,26.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,26.07,,,fee schedule,,,26.07,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CADMIUM,3063070,CDM,301,RC,82300,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CADMIUM,3063070,CDM,301,RC,82300,CPT,,,,,,outpatient,facility,,,71,29.82,19.17,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,23.64,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,24.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,23.64,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,34.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.91,,,fee schedule,,,20.99,,,fee schedule,,,20.99,,,fee schedule,,,20.57,,,fee schedule,,,23.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,23.64,,,fee schedule,,,23.64,,,fee schedule,,,28.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CAFFEINE,3063088,CDM,301,RC,80155,CPT,,,,,,inpatient,facility,,,116,48.72,98.6,111.36,,98.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,104.4,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CAFFEINE,3063088,CDM,301,RC,80155,CPT,,,,,,outpatient,facility,,,116,48.72,16.94,111.36,,98.6,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,79.81,,,percent of total billed charges,,,78.07,,,percent of total billed charges,,,98.02,,,percent of total billed charges,,,38.57,,,fee schedule,,,100.92,,,percent of total billed charges,,,100.92,,,percent of total billed charges,,,98.6,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,39.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",104.4,,,percent of total billed charges,,,38.57,,,fee schedule,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,55.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.07,,,fee schedule,,,34.25,,,fee schedule,,,34.25,,,fee schedule,,,33.57,,,fee schedule,,,38.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",90.6,,,percent of total billed charges,,,105.56,,,percent of total billed charges,,,38.57,,,fee schedule,,,38.57,,,fee schedule,,,16.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCITONIN,3063096,CDM,301,RC,82308,CPT,,,,,,inpatient,facility,,,81,34.02,68.85,77.76,,68.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.47,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCITONIN,3063096,CDM,301,RC,82308,CPT,,,,,,outpatient,facility,,,81,34.02,21.87,77.76,,68.85,,,percent of total billed charges,,,21.87,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,54.51,,,percent of total billed charges,,,68.44,,,percent of total billed charges,,,26.79,,,fee schedule,,,70.47,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,27.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72.9,,,percent of total billed charges,,,26.79,,,fee schedule,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,38.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.17,,,fee schedule,,,23.79,,,fee schedule,,,23.79,,,fee schedule,,,23.31,,,fee schedule,,,26.79,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",63.26,,,percent of total billed charges,,,73.71,,,percent of total billed charges,,,26.79,,,fee schedule,,,26.79,,,fee schedule,,,32.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCIUM IONIZED,3063104,CDM,301,RC,82330,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCIUM IONIZED,3063104,CDM,301,RC,82330,CPT,,,,,,outpatient,facility,,,54,22.68,11.91,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,13.68,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,13.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,13.68,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,19.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.47,,,fee schedule,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,11.91,,,fee schedule,,,13.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,13.68,,,fee schedule,,,13.68,,,fee schedule,,,16.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCIUM TOTAL,3063112,CDM,301,RC,82310,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCIUM TOTAL,3063112,CDM,301,RC,82310,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.16,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.16,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.97,,,fee schedule,,,4.58,,,fee schedule,,,4.58,,,fee schedule,,,4.49,,,fee schedule,,,5.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.16,,,fee schedule,,,5.16,,,fee schedule,,,6.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCIUM TOTAL URINE,3063120,CDM,301,RC,82310,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCIUM TOTAL URINE,3063120,CDM,301,RC,82310,CPT,,,,,,outpatient,facility,,,56,23.52,4.49,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.16,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.16,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,7.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.97,,,fee schedule,,,4.58,,,fee schedule,,,4.58,,,fee schedule,,,4.49,,,fee schedule,,,5.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.16,,,fee schedule,,,5.16,,,fee schedule,,,6.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCIUM URINE QN TIMED,3063138,CDM,301,RC,82340,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCIUM URINE QN TIMED,3063138,CDM,301,RC,82340,CPT,,,,,,outpatient,facility,,,56,23.52,5.24,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.03,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,6.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,6.03,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,8.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.14,,,fee schedule,,,5.35,,,fee schedule,,,5.35,,,fee schedule,,,5.24,,,fee schedule,,,6.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,6.03,,,fee schedule,,,6.03,,,fee schedule,,,7.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCULUS SPECTROSCOPY INFRARED,3063146,CDM,301,RC,82365,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCULUS SPECTROSCOPY INFRARED,3063146,CDM,301,RC,82365,CPT,,,,,,outpatient,facility,,,74,31.08,10.67,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,12.9,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,13.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,12.9,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,18.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.42,,,fee schedule,,,11.46,,,fee schedule,,,11.46,,,fee schedule,,,11.23,,,fee schedule,,,12.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,12.9,,,fee schedule,,,12.9,,,fee schedule,,,10.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARBAMAZEPINE TOTAL,3063179,CDM,301,RC,80156,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARBAMAZEPINE TOTAL,3063179,CDM,301,RC,80156,CPT,,,,,,outpatient,facility,,,52,21.84,12.68,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,14.57,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,14.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,14.57,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,21.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.67,,,fee schedule,,,12.94,,,fee schedule,,,12.94,,,fee schedule,,,12.68,,,fee schedule,,,14.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,14.57,,,fee schedule,,,14.57,,,fee schedule,,,17.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARBON DIOXIDE HCO3,3063187,CDM,301,RC,82374,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARBON DIOXIDE HCO3,3063187,CDM,301,RC,82374,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.88,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.88,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,7.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.59,,,fee schedule,,,4.33,,,fee schedule,,,4.33,,,fee schedule,,,4.24,,,fee schedule,,,4.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.88,,,fee schedule,,,4.88,,,fee schedule,,,6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARBOXYHEMOGLOBIN QN NS,3063195,CDM,301,RC,82375,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARBOXYHEMOGLOBIN QN NS,3063195,CDM,301,RC,82375,CPT,,,,,,outpatient,facility,,,75,31.5,10.72,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,12.32,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,12.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,12.32,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,17.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.63,,,fee schedule,,,10.94,,,fee schedule,,,10.94,,,fee schedule,,,10.72,,,fee schedule,,,12.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,12.32,,,fee schedule,,,12.32,,,fee schedule,,,15.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AG CARCINOEMBRYONIC,3063203,CDM,301,RC,82378,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AG CARCINOEMBRYONIC,3063203,CDM,301,RC,82378,CPT,,,,,,outpatient,facility,,,57,23.94,15.39,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,18.96,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,19.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,18.96,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,27.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.6,,,fee schedule,,,16.84,,,fee schedule,,,16.84,,,fee schedule,,,16.5,,,fee schedule,,,18.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,18.96,,,fee schedule,,,18.96,,,fee schedule,,,23.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARNITINE TOTAL ANDFREE QN,3063237,CDM,301,RC,82379,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARNITINE TOTAL ANDFREE QN,3063237,CDM,301,RC,82379,CPT,,,,,,outpatient,facility,,,51,21.42,5.84,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.87,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.87,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.77,,,fee schedule,,,14.98,,,fee schedule,,,14.98,,,fee schedule,,,14.68,,,fee schedule,,,16.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.87,,,fee schedule,,,16.87,,,fee schedule,,,5.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CAROTENE,3063252,CDM,301,RC,82380,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CAROTENE,3063252,CDM,301,RC,82380,CPT,,,,,,outpatient,facility,,,67,28.14,8.03,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,9.22,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,9.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,9.22,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,13.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.45,,,fee schedule,,,8.19,,,fee schedule,,,8.19,,,fee schedule,,,8.03,,,fee schedule,,,9.22,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,9.22,,,fee schedule,,,9.22,,,fee schedule,,,9.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CATECHOLAMINES FRACTIONATED,3063278,CDM,301,RC,82384,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CATECHOLAMINES FRACTIONATED,3063278,CDM,301,RC,82384,CPT,,,,,,outpatient,facility,,,76,31.92,20.52,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,25.25,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,25.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,25.25,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,36.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.09,,,fee schedule,,,22.42,,,fee schedule,,,22.42,,,fee schedule,,,21.97,,,fee schedule,,,25.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,25.25,,,fee schedule,,,25.25,,,fee schedule,,,30.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CERULOPLASMIN,3063302,CDM,301,RC,82390,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CERULOPLASMIN,3063302,CDM,301,RC,82390,CPT,,,,,,outpatient,facility,,,53,22.26,9.35,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,10.74,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,10.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,10.74,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,15.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.5,,,fee schedule,,,9.54,,,fee schedule,,,9.54,,,fee schedule,,,9.35,,,fee schedule,,,10.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,10.74,,,fee schedule,,,10.74,,,fee schedule,,,13.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHEMILUMINESCENT,3063328,CDM,301,RC,82397,CPT,,,,,,inpatient,facility,,,70,29.4,59.5,67.2,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.9,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHEMILUMINESCENT,3063328,CDM,301,RC,82397,CPT,,,,,,outpatient,facility,,,70,29.4,12.29,67.2,,59.5,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,47.11,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,14.12,,,fee schedule,,,60.9,,,percent of total billed charges,,,60.9,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,14.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63,,,percent of total billed charges,,,14.12,,,fee schedule,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,20.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.06,,,fee schedule,,,12.54,,,fee schedule,,,12.54,,,fee schedule,,,12.29,,,fee schedule,,,14.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",54.67,,,percent of total billed charges,,,63.7,,,percent of total billed charges,,,14.12,,,fee schedule,,,14.12,,,fee schedule,,,17.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHLORIDE BLOOD,3063351,CDM,301,RC,82435,CPT,,,,,,inpatient,facility,,,14,5.88,11.9,13.44,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHLORIDE BLOOD,3063351,CDM,301,RC,82435,CPT,,,,,,outpatient,facility,,,14,5.88,3.78,13.44,,11.9,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.6,,,fee schedule,,,12.18,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,11.9,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,4.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.6,,,percent of total billed charges,,,4.6,,,fee schedule,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,6.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.21,,,fee schedule,,,4.08,,,fee schedule,,,4.08,,,fee schedule,,,4,,,fee schedule,,,4.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.93,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,5.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHLORIDE FLUID BODY,3063369,CDM,301,RC,82438,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHLORIDE FLUID BODY,3063369,CDM,301,RC,82438,CPT,,,,,,outpatient,facility,,,51,21.42,2.8,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,5,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,5.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,5,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,7.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.75,,,fee schedule,,,4.44,,,fee schedule,,,4.44,,,fee schedule,,,4.35,,,fee schedule,,,5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,5,,,fee schedule,,,5,,,fee schedule,,,2.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHLORIDE URINE,3063401,CDM,301,RC,82436,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHLORIDE URINE,3063401,CDM,301,RC,82436,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.75,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.75,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.76,,,fee schedule,,,5.11,,,fee schedule,,,5.11,,,fee schedule,,,5.01,,,fee schedule,,,5.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,6.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHOLESTEROL SRM BLD WHL TTL,3063419,CDM,301,RC,82465,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHOLESTEROL SRM BLD WHL TTL,3063419,CDM,301,RC,82465,CPT,,,,,,outpatient,facility,,,55,23.1,3.78,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,4.35,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,4.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,4.35,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,6.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.87,,,fee schedule,,,3.86,,,fee schedule,,,3.86,,,fee schedule,,,3.78,,,fee schedule,,,4.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,4.35,,,fee schedule,,,4.35,,,fee schedule,,,5.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN CHOLESTEROL HDL,3063427,CDM,301,RC,83718,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN CHOLESTEROL HDL,3063427,CDM,301,RC,83718,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.19,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.19,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.06,,,fee schedule,,,7.27,,,fee schedule,,,7.27,,,fee schedule,,,7.12,,,fee schedule,,,8.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.19,,,fee schedule,,,8.19,,,fee schedule,,,7.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHOLINESTERASE RBC,3063450,CDM,301,RC,82482,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHOLINESTERASE RBC,3063450,CDM,301,RC,82482,CPT,,,,,,outpatient,facility,,,59,24.78,8.54,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,9.81,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,10.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,9.81,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,14.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.24,,,fee schedule,,,8.71,,,fee schedule,,,8.71,,,fee schedule,,,8.54,,,fee schedule,,,9.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,9.81,,,fee schedule,,,9.81,,,fee schedule,,,9.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CITRATE,3063559,CDM,301,RC,82507,CPT,,,,,,inpatient,facility,,,84,35.28,71.4,80.64,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.08,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CITRATE,3063559,CDM,301,RC,82507,CPT,,,,,,outpatient,facility,,,84,35.28,22.68,80.64,,71.4,,,percent of total billed charges,,,22.68,,,percent of total billed charges,,,57.79,,,percent of total billed charges,,,56.53,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,27.8,,,fee schedule,,,73.08,,,percent of total billed charges,,,73.08,,,percent of total billed charges,,,71.4,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,28.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",75.6,,,percent of total billed charges,,,27.8,,,fee schedule,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,40.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.53,,,fee schedule,,,24.69,,,fee schedule,,,24.69,,,fee schedule,,,24.2,,,fee schedule,,,27.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",65.6,,,percent of total billed charges,,,76.44,,,percent of total billed charges,,,27.8,,,fee schedule,,,27.8,,,fee schedule,,,34.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL METAB COMP,3063641,CDM,301,RC,80053,CPT,,,,,,inpatient,facility,,,32,13.44,27.2,30.72,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.84,,,percent of total billed charges,,,,,,,,,28.8,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.76,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL METAB COMP,3063641,CDM,301,RC,80053,CPT,,,,,,outpatient,facility,,,32,13.44,8.64,30.72,,27.2,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,27.04,,,percent of total billed charges,,,10.56,,,fee schedule,,,27.84,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,10.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.8,,,percent of total billed charges,,,10.56,,,fee schedule,,,29.76,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,15.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.26,,,fee schedule,,,9.38,,,fee schedule,,,9.38,,,fee schedule,,,9.19,,,fee schedule,,,10.56,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",24.99,,,percent of total billed charges,,,29.12,,,percent of total billed charges,,,10.56,,,fee schedule,,,10.56,,,fee schedule,,,12.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COPPER TISSUE NS,3063674,CDM,301,RC,82525,CPT,,,,,,inpatient,facility,,,211,88.62,179.35,202.56,,179.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.57,,,percent of total billed charges,,,,,,,,,189.9,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COPPER TISSUE NS,3063674,CDM,301,RC,82525,CPT,,,,,,outpatient,facility,,,211,88.62,10.8,202.56,,179.35,,,percent of total billed charges,,,56.97,,,percent of total billed charges,,,145.17,,,percent of total billed charges,,,142,,,percent of total billed charges,,,178.29,,,percent of total billed charges,,,12.41,,,fee schedule,,,183.57,,,percent of total billed charges,,,183.57,,,percent of total billed charges,,,179.35,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,12.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",189.9,,,percent of total billed charges,,,12.41,,,fee schedule,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,17.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.75,,,fee schedule,,,11.02,,,fee schedule,,,11.02,,,fee schedule,,,10.8,,,fee schedule,,,12.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",164.79,,,percent of total billed charges,,,192.01,,,percent of total billed charges,,,12.41,,,fee schedule,,,12.41,,,fee schedule,,,15.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COPPER URINE,3063682,CDM,301,RC,82525,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COPPER URINE,3063682,CDM,301,RC,82525,CPT,,,,,,outpatient,facility,,,65,27.3,10.8,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,12.41,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,12.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,12.41,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,17.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.75,,,fee schedule,,,11.02,,,fee schedule,,,11.02,,,fee schedule,,,10.8,,,fee schedule,,,12.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,12.41,,,fee schedule,,,12.41,,,fee schedule,,,15.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CORTICOSTERONE,3063690,CDM,301,RC,82528,CPT,,,,,,inpatient,facility,,,83,34.86,70.55,79.68,,70.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.21,,,percent of total billed charges,,,,,,,,,74.7,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CORTICOSTERONE,3063690,CDM,301,RC,82528,CPT,,,,,,outpatient,facility,,,83,34.86,19.6,79.68,,70.55,,,percent of total billed charges,,,22.41,,,percent of total billed charges,,,57.1,,,percent of total billed charges,,,55.86,,,percent of total billed charges,,,70.13,,,percent of total billed charges,,,22.52,,,fee schedule,,,72.21,,,percent of total billed charges,,,72.21,,,percent of total billed charges,,,70.55,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,22.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.7,,,percent of total billed charges,,,22.52,,,fee schedule,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,32.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.4,,,fee schedule,,,20,,,fee schedule,,,20,,,fee schedule,,,19.6,,,fee schedule,,,22.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.82,,,percent of total billed charges,,,75.53,,,percent of total billed charges,,,22.52,,,fee schedule,,,22.52,,,fee schedule,,,27.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CORTISOL FREE,3063708,CDM,301,RC,82530,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CORTISOL FREE,3063708,CDM,301,RC,82530,CPT,,,,,,outpatient,facility,,,55,23.1,14.54,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,16.71,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,16.71,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,24.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.56,,,fee schedule,,,14.84,,,fee schedule,,,14.84,,,fee schedule,,,14.54,,,fee schedule,,,16.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,16.71,,,fee schedule,,,16.71,,,fee schedule,,,20.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CORTISOL TOTAL,3063716,CDM,301,RC,82533,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CORTISOL TOTAL,3063716,CDM,301,RC,82533,CPT,,,,,,outpatient,facility,,,58,24.36,14.18,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,16.3,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,16.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,16.3,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,23.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.01,,,fee schedule,,,14.47,,,fee schedule,,,14.47,,,fee schedule,,,14.18,,,fee schedule,,,16.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,16.3,,,fee schedule,,,16.3,,,fee schedule,,,19.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CORTISOL TOTAL NS,3063724,CDM,301,RC,82533,CPT,,,,,,inpatient,facility,,,323,135.66,274.55,310.08,,274.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.01,,,percent of total billed charges,,,,,,,,,290.7,,,percent of total billed charges,,,310.08,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,300.39,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CORTISOL TOTAL NS,3063724,CDM,301,RC,82533,CPT,,,,,,outpatient,facility,,,323,135.66,14.18,310.08,,274.55,,,percent of total billed charges,,,87.21,,,percent of total billed charges,,,222.22,,,percent of total billed charges,,,217.38,,,percent of total billed charges,,,272.94,,,percent of total billed charges,,,16.3,,,fee schedule,,,281.01,,,percent of total billed charges,,,281.01,,,percent of total billed charges,,,274.55,,,percent of total billed charges,,,310.08,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,16.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",290.7,,,percent of total billed charges,,,16.3,,,fee schedule,,,300.39,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,23.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.01,,,fee schedule,,,14.47,,,fee schedule,,,14.47,,,fee schedule,,,14.18,,,fee schedule,,,16.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",252.26,,,percent of total billed charges,,,293.93,,,percent of total billed charges,,,16.3,,,fee schedule,,,16.3,,,fee schedule,,,19.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB C PEPTIDE,3063732,CDM,301,RC,84681,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB C PEPTIDE,3063732,CDM,301,RC,84681,CPT,,,,,,outpatient,facility,,,63,26.46,17.01,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,20.81,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,20.81,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,30.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.09,,,fee schedule,,,18.48,,,fee schedule,,,18.48,,,fee schedule,,,18.11,,,fee schedule,,,20.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,20.81,,,fee schedule,,,20.81,,,fee schedule,,,25.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATINE KINASE ISOENZYMES,3063740,CDM,301,RC,82552,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATINE KINASE ISOENZYMES,3063740,CDM,301,RC,82552,CPT,,,,,,outpatient,facility,,,59,24.78,11.65,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,13.39,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,13.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,13.39,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,19.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.08,,,fee schedule,,,11.89,,,fee schedule,,,11.89,,,fee schedule,,,11.65,,,fee schedule,,,13.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,13.39,,,fee schedule,,,13.39,,,fee schedule,,,16.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATINE KINASE MB ONLY QN,3063765,CDM,301,RC,82553,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATINE KINASE MB ONLY QN,3063765,CDM,301,RC,82553,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.55,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.55,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.59,,,fee schedule,,,10.26,,,fee schedule,,,10.26,,,fee schedule,,,10.05,,,fee schedule,,,11.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,14.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATINE URINE,3063781,CDM,301,RC,82540,CPT,,,,,,inpatient,facility,,,14,5.88,11.9,13.44,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATINE URINE,3063781,CDM,301,RC,82540,CPT,,,,,,outpatient,facility,,,14,5.88,3.78,13.44,,11.9,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.64,,,fee schedule,,,12.18,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,11.9,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,4.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.6,,,percent of total billed charges,,,4.64,,,fee schedule,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,6.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.26,,,fee schedule,,,4.12,,,fee schedule,,,4.12,,,fee schedule,,,4.04,,,fee schedule,,,4.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.93,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,4.64,,,fee schedule,,,4.64,,,fee schedule,,,5.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATININE BLOOD,3063799,CDM,301,RC,82565,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATININE BLOOD,3063799,CDM,301,RC,82565,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.12,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.12,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.91,,,fee schedule,,,4.55,,,fee schedule,,,4.55,,,fee schedule,,,4.46,,,fee schedule,,,5.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.12,,,fee schedule,,,5.12,,,fee schedule,,,6.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATININE FLUID BODY,3063807,CDM,301,RC,82570,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATININE FLUID BODY,3063807,CDM,301,RC,82570,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.18,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.18,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATININE CLEARANCE,3063815,CDM,301,RC,82575,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATININE CLEARANCE,3063815,CDM,301,RC,82575,CPT,,,,,,outpatient,facility,,,29,12.18,7.83,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.46,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.46,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.77,,,fee schedule,,,8.4,,,fee schedule,,,8.4,,,fee schedule,,,8.23,,,fee schedule,,,9.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.46,,,fee schedule,,,9.46,,,fee schedule,,,11.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATINE KINASE TOTAL,3063823,CDM,301,RC,82550,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATINE KINASE TOTAL,3063823,CDM,301,RC,82550,CPT,,,,,,outpatient,facility,,,20,8.4,5.4,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.51,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.51,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.79,,,fee schedule,,,5.78,,,fee schedule,,,5.78,,,fee schedule,,,5.66,,,fee schedule,,,6.51,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.51,,,fee schedule,,,6.51,,,fee schedule,,,7.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATININE OTHER SOURCE,3063831,CDM,301,RC,82570,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATININE OTHER SOURCE,3063831,CDM,301,RC,82570,CPT,,,,,,outpatient,facility,,,80,33.6,4.51,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,5.18,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,5.18,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATININE URINE,3063849,CDM,301,RC,82570,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATININE URINE,3063849,CDM,301,RC,82570,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.18,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.18,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CRYOGLOBULIN QL SEMI QN,3063864,CDM,301,RC,82595,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CRYOGLOBULIN QL SEMI QN,3063864,CDM,301,RC,82595,CPT,,,,,,outpatient,facility,,,63,26.46,3.48,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,6.47,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,6.47,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,3.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYCLOSPORINE,3063880,CDM,301,RC,80158,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYCLOSPORINE,3063880,CDM,301,RC,80158,CPT,,,,,,outpatient,facility,,,55,23.1,14.02,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,18.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,18.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.37,,,fee schedule,,,16.03,,,fee schedule,,,16.03,,,fee schedule,,,15.71,,,fee schedule,,,18.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,18.05,,,fee schedule,,,18.05,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYCLOSPORINE A,3063898,CDM,301,RC,80158,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYCLOSPORINE A,3063898,CDM,301,RC,80158,CPT,,,,,,outpatient,facility,,,58,24.36,14.02,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,18.05,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,18.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,18.05,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,26.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.37,,,fee schedule,,,16.03,,,fee schedule,,,16.03,,,fee schedule,,,15.71,,,fee schedule,,,18.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,18.05,,,fee schedule,,,18.05,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DEOXYCORTISOL 11,3063922,CDM,301,RC,82634,CPT,,,,,,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DEOXYCORTISOL 11,3063922,CDM,301,RC,82634,CPT,,,,,,outpatient,facility,,,88,36.96,23.76,84.48,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,29.28,,,fee schedule,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,29.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",79.2,,,percent of total billed charges,,,29.28,,,fee schedule,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,42.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.53,,,fee schedule,,,26,,,fee schedule,,,26,,,fee schedule,,,25.48,,,fee schedule,,,29.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,29.28,,,fee schedule,,,29.28,,,fee schedule,,,35.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DESOXYCORTICOSTERONE,3063948,CDM,301,RC,82633,CPT,,,,,,inpatient,facility,,,93,39.06,79.05,89.28,,79.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.91,,,percent of total billed charges,,,,,,,,,83.7,,,percent of total billed charges,,,89.28,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.49,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DESOXYCORTICOSTERONE,3063948,CDM,301,RC,82633,CPT,,,,,,outpatient,facility,,,93,39.06,25.11,89.28,,79.05,,,percent of total billed charges,,,25.11,,,percent of total billed charges,,,63.98,,,percent of total billed charges,,,62.59,,,percent of total billed charges,,,78.58,,,percent of total billed charges,,,30.98,,,fee schedule,,,80.91,,,percent of total billed charges,,,80.91,,,percent of total billed charges,,,79.05,,,percent of total billed charges,,,89.28,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,31.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.7,,,percent of total billed charges,,,30.98,,,fee schedule,,,86.49,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,44.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.82,,,fee schedule,,,27.51,,,fee schedule,,,27.51,,,fee schedule,,,26.96,,,fee schedule,,,30.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",72.63,,,percent of total billed charges,,,84.63,,,percent of total billed charges,,,30.98,,,fee schedule,,,30.98,,,fee schedule,,,37.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DEHYDROEPIANDROSTERONE,3063955,CDM,301,RC,82626,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DEHYDROEPIANDROSTERONE,3063955,CDM,301,RC,82626,CPT,,,,,,outpatient,facility,,,76,31.92,20.52,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,25.27,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,25.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,25.27,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,36.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.11,,,fee schedule,,,22.44,,,fee schedule,,,22.44,,,fee schedule,,,21.99,,,fee schedule,,,25.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,25.27,,,fee schedule,,,25.27,,,fee schedule,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DEHYDROEPIANDROSTERONE SULFATE,3063963,CDM,301,RC,82627,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DEHYDROEPIANDROSTERONE SULFATE,3063963,CDM,301,RC,82627,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,22.23,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,22.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,22.23,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,32.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.01,,,fee schedule,,,19.74,,,fee schedule,,,19.74,,,fee schedule,,,19.35,,,fee schedule,,,22.23,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,22.23,,,fee schedule,,,22.23,,,fee schedule,,,27.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL ELECTROLYTE,3064482,CDM,301,RC,80051,CPT,,,,,,inpatient,facility,,,22,9.24,18.7,21.12,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL ELECTROLYTE,3064482,CDM,301,RC,80051,CPT,,,,,,outpatient,facility,,,22,9.24,5.94,21.12,,18.7,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,14.81,,,percent of total billed charges,,,18.59,,,percent of total billed charges,,,7.01,,,fee schedule,,,19.14,,,percent of total billed charges,,,19.14,,,percent of total billed charges,,,18.7,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,7.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.8,,,percent of total billed charges,,,7.01,,,fee schedule,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,10.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.46,,,fee schedule,,,6.22,,,fee schedule,,,6.22,,,fee schedule,,,6.1,,,fee schedule,,,7.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",17.18,,,percent of total billed charges,,,20.02,,,percent of total billed charges,,,7.01,,,fee schedule,,,7.01,,,fee schedule,,,7.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT FRCTN ELECTRO ANDQN SERUM,3064490,CDM,301,RC,84165,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT FRCTN ELECTRO ANDQN SERUM,3064490,CDM,301,RC,84165,CPT,,,,,,outpatient,facility,,,57,23.94,9.35,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,10.74,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,10.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,10.74,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,15.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.5,,,fee schedule,,,9.54,,,fee schedule,,,9.54,,,fee schedule,,,9.35,,,fee schedule,,,10.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,10.74,,,fee schedule,,,10.74,,,fee schedule,,,13.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ELECTRO,3064516,CDM,301,RC,82664,CPT,,,,,,inpatient,facility,,,185,77.7,157.25,177.6,,157.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.95,,,percent of total billed charges,,,,,,,,,166.5,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.05,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ELECTRO,3064516,CDM,301,RC,82664,CPT,,,,,,outpatient,facility,,,185,77.7,42.12,177.6,,157.25,,,percent of total billed charges,,,49.95,,,percent of total billed charges,,,127.28,,,percent of total billed charges,,,124.5,,,percent of total billed charges,,,156.32,,,percent of total billed charges,,,61.5,,,fee schedule,,,160.95,,,percent of total billed charges,,,160.95,,,percent of total billed charges,,,157.25,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,62.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",166.5,,,percent of total billed charges,,,61.5,,,fee schedule,,,172.05,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,89.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.03,,,fee schedule,,,54.61,,,fee schedule,,,54.61,,,fee schedule,,,53.52,,,fee schedule,,,61.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",144.48,,,percent of total billed charges,,,168.35,,,percent of total billed charges,,,61.5,,,fee schedule,,,61.5,,,fee schedule,,,42.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACTIVITY ENZYME NONRADIOACTIVE,3064532,CDM,301,RC,82657,CPT,,,,,,inpatient,facility,,,112,47.04,95.2,107.52,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACTIVITY ENZYME NONRADIOACTIVE,3064532,CDM,301,RC,82657,CPT,,,,,,outpatient,facility,,,112,47.04,14.06,107.52,,95.2,,,percent of total billed charges,,,30.24,,,percent of total billed charges,,,77.06,,,percent of total billed charges,,,75.38,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,22.17,,,fee schedule,,,97.44,,,percent of total billed charges,,,97.44,,,percent of total billed charges,,,95.2,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,22.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.8,,,percent of total billed charges,,,22.17,,,fee schedule,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,32.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.93,,,fee schedule,,,19.69,,,fee schedule,,,19.69,,,fee schedule,,,19.3,,,fee schedule,,,22.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",87.47,,,percent of total billed charges,,,101.92,,,percent of total billed charges,,,22.17,,,fee schedule,,,22.17,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ERYTHROPOIETIN,3064540,CDM,301,RC,82668,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ERYTHROPOIETIN,3064540,CDM,301,RC,82668,CPT,,,,,,outpatient,facility,,,57,23.94,15.39,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,18.79,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,19.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,18.79,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,27.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.37,,,fee schedule,,,16.69,,,fee schedule,,,16.69,,,fee schedule,,,16.36,,,fee schedule,,,18.79,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,18.79,,,fee schedule,,,18.79,,,fee schedule,,,22.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ESTRIOL SERUM NS,3064565,CDM,301,RC,82677,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ESTRIOL SERUM NS,3064565,CDM,301,RC,82677,CPT,,,,,,outpatient,facility,,,73,30.66,19.71,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,24.18,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,24.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,24.18,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,35.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.64,,,fee schedule,,,21.47,,,fee schedule,,,21.47,,,fee schedule,,,21.04,,,fee schedule,,,24.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,24.18,,,fee schedule,,,24.18,,,fee schedule,,,29.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ESTROGENS FRACTIONATED,3064599,CDM,301,RC,82671,CPT,,,,,,inpatient,facility,,,98,41.16,83.3,94.08,,83.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.26,,,percent of total billed charges,,,,,,,,,88.2,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ESTROGENS FRACTIONATED,3064599,CDM,301,RC,82671,CPT,,,,,,outpatient,facility,,,98,41.16,26.46,94.08,,83.3,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,67.42,,,percent of total billed charges,,,65.95,,,percent of total billed charges,,,82.81,,,percent of total billed charges,,,32.3,,,fee schedule,,,85.26,,,percent of total billed charges,,,85.26,,,percent of total billed charges,,,83.3,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,32.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.2,,,percent of total billed charges,,,32.3,,,fee schedule,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,46.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",43.6,,,fee schedule,,,28.68,,,fee schedule,,,28.68,,,fee schedule,,,28.11,,,fee schedule,,,32.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",76.54,,,percent of total billed charges,,,89.18,,,percent of total billed charges,,,32.3,,,fee schedule,,,32.3,,,fee schedule,,,39.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ESTRONE,3064607,CDM,301,RC,82679,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ESTRONE,3064607,CDM,301,RC,82679,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,24.95,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,25.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,24.95,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,36.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.68,,,fee schedule,,,22.16,,,fee schedule,,,22.16,,,fee schedule,,,21.72,,,fee schedule,,,24.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,24.95,,,fee schedule,,,24.95,,,fee schedule,,,30.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ETHYLENE GLYCOL,3064649,CDM,301,RC,82693,CPT,,,,,,inpatient,facility,,,81,34.02,68.85,77.76,,68.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.47,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ETHYLENE GLYCOL,3064649,CDM,301,RC,82693,CPT,,,,,,outpatient,facility,,,81,34.02,12.97,77.76,,68.85,,,percent of total billed charges,,,21.87,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,54.51,,,percent of total billed charges,,,68.44,,,percent of total billed charges,,,14.9,,,fee schedule,,,70.47,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,15.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72.9,,,percent of total billed charges,,,14.9,,,fee schedule,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,21.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.12,,,fee schedule,,,13.23,,,fee schedule,,,13.23,,,fee schedule,,,12.97,,,fee schedule,,,14.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",63.26,,,percent of total billed charges,,,73.71,,,percent of total billed charges,,,14.9,,,fee schedule,,,14.9,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FAT LIPIDS FECES QN,3064763,CDM,301,RC,82710,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FAT LIPIDS FECES QN,3064763,CDM,301,RC,82710,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.8,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.8,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.68,,,fee schedule,,,14.92,,,fee schedule,,,14.92,,,fee schedule,,,14.62,,,fee schedule,,,16.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.8,,,fee schedule,,,16.8,,,fee schedule,,,20.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS FATTY NONESTERIFIED,3064771,CDM,301,RC,82725,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS FATTY NONESTERIFIED,3064771,CDM,301,RC,82725,CPT,,,,,,outpatient,facility,,,69,28.98,16.32,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,18.77,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,19.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,18.77,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,27.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.34,,,fee schedule,,,16.67,,,fee schedule,,,16.67,,,fee schedule,,,16.34,,,fee schedule,,,18.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,18.77,,,fee schedule,,,18.77,,,fee schedule,,,16.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FELBAMATE,3064789,CDM,301,RC,80167,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FELBAMATE,3064789,CDM,301,RC,80167,CPT,,,,,,outpatient,facility,,,74,31.08,16.22,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,18.64,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,18.64,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FERRITIN,3064797,CDM,301,RC,82728,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FERRITIN,3064797,CDM,301,RC,82728,CPT,,,,,,outpatient,facility,,,60,25.2,11.86,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,13.63,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,13.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,13.63,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,19.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.4,,,fee schedule,,,12.1,,,fee schedule,,,12.1,,,fee schedule,,,11.86,,,fee schedule,,,13.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,13.63,,,fee schedule,,,13.63,,,fee schedule,,,16.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FIBRONECTIN FETAL SEMI QL,3064805,CDM,301,RC,82731,CPT,,,,,,inpatient,facility,,,194,81.48,164.9,186.24,,164.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.78,,,percent of total billed charges,,,,,,,,,174.6,,,percent of total billed charges,,,186.24,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.42,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FIBRONECTIN FETAL SEMI QL,3064805,CDM,301,RC,82731,CPT,,,,,,outpatient,facility,,,194,81.48,52.38,186.24,,164.9,,,percent of total billed charges,,,52.38,,,percent of total billed charges,,,133.47,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,163.93,,,percent of total billed charges,,,64.41,,,fee schedule,,,168.78,,,percent of total billed charges,,,168.78,,,percent of total billed charges,,,164.9,,,percent of total billed charges,,,186.24,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,65.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",174.6,,,percent of total billed charges,,,64.41,,,fee schedule,,,180.42,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,93.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",86.95,,,fee schedule,,,57.2,,,fee schedule,,,57.2,,,fee schedule,,,56.06,,,fee schedule,,,64.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",151.51,,,percent of total billed charges,,,176.54,,,percent of total billed charges,,,64.41,,,fee schedule,,,64.41,,,fee schedule,,,75.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FLECAINIDE,3064813,CDM,301,RC,80181,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FLECAINIDE,3064813,CDM,301,RC,80181,CPT,,,,,,outpatient,facility,,,68,28.56,16.22,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,18.64,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,18.64,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID FOLIC RBC,3064888,CDM,301,RC,82747,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID FOLIC RBC,3064888,CDM,301,RC,82747,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,17.65,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,17.65,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,25.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.83,,,fee schedule,,,15.67,,,fee schedule,,,15.67,,,fee schedule,,,15.36,,,fee schedule,,,17.65,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,17.65,,,fee schedule,,,17.65,,,fee schedule,,,21.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID FOLIC SERUM,3064896,CDM,301,RC,82746,CPT,,,,,,inpatient,facility,,,45,18.9,38.25,43.2,,38.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.15,,,percent of total billed charges,,,,,,,,,40.5,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.85,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID FOLIC SERUM,3064896,CDM,301,RC,82746,CPT,,,,,,outpatient,facility,,,45,18.9,12.15,43.2,,38.25,,,percent of total billed charges,,,12.15,,,percent of total billed charges,,,30.96,,,percent of total billed charges,,,30.28,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,14.7,,,fee schedule,,,39.15,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,,38.25,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,14.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",40.5,,,percent of total billed charges,,,14.7,,,fee schedule,,,41.85,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,21.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.84,,,fee schedule,,,13.05,,,fee schedule,,,13.05,,,fee schedule,,,12.79,,,fee schedule,,,14.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",35.14,,,percent of total billed charges,,,40.95,,,percent of total billed charges,,,14.7,,,fee schedule,,,14.7,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GONADOTROPIN FSH SERUM,3064904,CDM,301,RC,83001,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GONADOTROPIN FSH SERUM,3064904,CDM,301,RC,83001,CPT,,,,,,outpatient,facility,,,56,23.52,15.12,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,18.58,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,18.58,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,26.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.08,,,fee schedule,,,16.5,,,fee schedule,,,16.5,,,fee schedule,,,16.17,,,fee schedule,,,18.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,18.58,,,fee schedule,,,18.58,,,fee schedule,,,16.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GABAPENTIN SRM PLASMA BLD WHL,3064946,CDM,301,RC,80171,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GABAPENTIN SRM PLASMA BLD WHL,3064946,CDM,301,RC,80171,CPT,,,,,,outpatient,facility,,,77,32.34,15.87,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,21.67,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,22.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,21.67,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,31.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.25,,,fee schedule,,,19.24,,,fee schedule,,,19.24,,,fee schedule,,,18.86,,,fee schedule,,,21.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,21.67,,,fee schedule,,,21.67,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR TRANSFERASE GALACTOSE 1,3064961,CDM,301,RC,82776,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR TRANSFERASE GALACTOSE 1,3064961,CDM,301,RC,82776,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.74,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,11.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.74,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.85,,,fee schedule,,,10.43,,,fee schedule,,,10.43,,,fee schedule,,,10.22,,,fee schedule,,,11.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.74,,,fee schedule,,,11.74,,,fee schedule,,,10.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG IGE,3064979,CDM,301,RC,82785,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG IGE,3064979,CDM,301,RC,82785,CPT,,,,,,outpatient,facility,,,58,24.36,14.33,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,16.46,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,16.46,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,23.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.22,,,fee schedule,,,14.62,,,fee schedule,,,14.62,,,fee schedule,,,14.33,,,fee schedule,,,16.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,16.46,,,fee schedule,,,16.46,,,fee schedule,,,20.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GASES BLD PH ONLY,3064987,CDM,301,RC,82800,CPT,,,,,,inpatient,facility,,,33,13.86,28.05,31.68,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.71,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GASES BLD PH ONLY,3064987,CDM,301,RC,82800,CPT,,,,,,outpatient,facility,,,33,13.86,8.91,31.68,,28.05,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.21,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,11,,,fee schedule,,,28.71,,,percent of total billed charges,,,28.71,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,11.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.7,,,percent of total billed charges,,,11,,,fee schedule,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,15.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.85,,,fee schedule,,,9.77,,,fee schedule,,,9.77,,,fee schedule,,,9.57,,,fee schedule,,,11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",25.77,,,percent of total billed charges,,,30.03,,,percent of total billed charges,,,11,,,fee schedule,,,11,,,fee schedule,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB ANCA FL EA AB,3065000,CDM,302,RC,86036,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB ANCA FL EA AB,3065000,CDM,302,RC,86036,CPT,,,,,,outpatient,facility,,,54,22.68,10.49,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,12.05,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,12.05,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,10.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHANNEL CA VOLTAGE GATED,3065018,CDM,302,RC,86596,CPT,,,,,,inpatient,facility,,,444,186.48,377.4,426.24,,377.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.28,,,percent of total billed charges,,,,,,,,,399.6,,,percent of total billed charges,,,426.24,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,412.92,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHANNEL CA VOLTAGE GATED,3065018,CDM,302,RC,86596,CPT,,,,,,outpatient,facility,,,444,186.48,10.49,426.24,,377.4,,,percent of total billed charges,,,119.88,,,percent of total billed charges,,,305.47,,,percent of total billed charges,,,298.81,,,percent of total billed charges,,,375.18,,,percent of total billed charges,,,12.05,,,fee schedule,,,386.28,,,percent of total billed charges,,,386.28,,,percent of total billed charges,,,377.4,,,percent of total billed charges,,,426.24,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",399.6,,,percent of total billed charges,,,12.05,,,fee schedule,,,412.92,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",346.76,,,percent of total billed charges,,,404.04,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,,,,,,
LAB AB CYTOM FLOW MOG,3065026,CDM,302,RC,86363,CPT,,,,,,inpatient,facility,,,211,88.62,179.35,202.56,,179.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.57,,,percent of total billed charges,,,,,,,,,189.9,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CYTOM FLOW MOG,3065026,CDM,302,RC,86363,CPT,,,,,,outpatient,facility,,,211,88.62,32.83,202.56,,179.35,,,percent of total billed charges,,,56.97,,,percent of total billed charges,,,145.17,,,percent of total billed charges,,,142,,,percent of total billed charges,,,178.29,,,percent of total billed charges,,,37.73,,,fee schedule,,,183.57,,,percent of total billed charges,,,183.57,,,percent of total billed charges,,,179.35,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",189.9,,,percent of total billed charges,,,37.73,,,fee schedule,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",164.79,,,percent of total billed charges,,,192.01,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,,,,,,
LAB AFP SERUM MATERNAL,3071321,CDM,301,RC,82105,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AFP SERUM MATERNAL,3071321,CDM,301,RC,82105,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.77,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.77,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.64,,,fee schedule,,,14.89,,,fee schedule,,,14.89,,,fee schedule,,,14.59,,,fee schedule,,,16.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.77,,,fee schedule,,,16.77,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GONADOTROPIN FSH SERUM NS,3071560,CDM,301,RC,83001,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GONADOTROPIN FSH SERUM NS,3071560,CDM,301,RC,83001,CPT,,,,,,outpatient,facility,,,58,24.36,15.66,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,18.58,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,18.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,18.58,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,26.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.08,,,fee schedule,,,16.5,,,fee schedule,,,16.5,,,fee schedule,,,16.17,,,fee schedule,,,18.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,18.58,,,fee schedule,,,18.58,,,fee schedule,,,16.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HEP B PRB AMP,3072196,CDM,306,RC,87516,CPT,,,,,,inpatient,facility,,,135,56.7,114.75,129.6,,114.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.45,,,percent of total billed charges,,,,,,,,,121.5,,,percent of total billed charges,,,129.6,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,125.55,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HEP B PRB AMP,3072196,CDM,306,RC,87516,CPT,,,,,,outpatient,facility,,,135,56.7,30.54,129.6,,114.75,,,percent of total billed charges,,,36.45,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,90.85,,,percent of total billed charges,,,114.08,,,percent of total billed charges,,,35.09,,,fee schedule,,,117.45,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,114.75,,,percent of total billed charges,,,129.6,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",121.5,,,percent of total billed charges,,,35.09,,,fee schedule,,,125.55,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",105.44,,,percent of total billed charges,,,122.85,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS TRANSGLUTAMINASE NS,3072360,CDM,302,RC,86364,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS TRANSGLUTAMINASE NS,3072360,CDM,302,RC,86364,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.53,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.53,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,10.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENOTYPE IA HIV 1 DRUGS 1 10,3072626,CDM,306,RC,87903,CPT,,,,,,inpatient,facility,,,1466,615.72,1246.1,1407.36,,1246.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1275.42,,,percent of total billed charges,,,,,,,,,1319.4,,,percent of total billed charges,,,1407.36,,,percent of total billed charges,,,1392.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1363.38,,,percent of total billed charges,,,1392.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENOTYPE IA HIV 1 DRUGS 1 10,3072626,CDM,306,RC,87903,CPT,,,,,,outpatient,facility,,,1466,615.72,395.82,1407.36,,1246.1,,,percent of total billed charges,,,395.82,,,percent of total billed charges,,,1008.61,,,percent of total billed charges,,,986.62,,,percent of total billed charges,,,1238.77,,,percent of total billed charges,,,488.66,,,fee schedule,,,1275.42,,,percent of total billed charges,,,1275.42,,,percent of total billed charges,,,1246.1,,,percent of total billed charges,,,1407.36,,,percent of total billed charges,,,1392.7,,,percent of total billed charges,,,498.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1319.4,,,percent of total billed charges,,,488.66,,,fee schedule,,,1363.38,,,percent of total billed charges,,,1392.7,,,percent of total billed charges,,,708.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",659.69,,,fee schedule,,,433.93,,,fee schedule,,,433.93,,,fee schedule,,,425.25,,,fee schedule,,,488.66,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1144.95,,,percent of total billed charges,,,1334.06,,,percent of total billed charges,,,488.66,,,fee schedule,,,488.66,,,fee schedule,,,599.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENOTYPE IA HIV 1 DRUGS ADDL,3072634,CDM,306,RC,87904,CPT,,,,,,inpatient,facility,,,91,38.22,77.35,87.36,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,79.17,,,percent of total billed charges,,,,,,,,,81.9,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,84.63,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENOTYPE IA HIV 1 DRUGS ADDL,3072634,CDM,306,RC,87904,CPT,,,,,,outpatient,facility,,,91,38.22,22.69,87.36,,77.35,,,percent of total billed charges,,,24.57,,,percent of total billed charges,,,62.61,,,percent of total billed charges,,,61.24,,,percent of total billed charges,,,76.89,,,percent of total billed charges,,,26.07,,,fee schedule,,,79.17,,,percent of total billed charges,,,79.17,,,percent of total billed charges,,,77.35,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81.9,,,percent of total billed charges,,,26.07,,,fee schedule,,,84.63,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,37.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.19,,,fee schedule,,,23.15,,,fee schedule,,,23.15,,,fee schedule,,,22.69,,,fee schedule,,,26.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",71.07,,,percent of total billed charges,,,82.81,,,percent of total billed charges,,,26.07,,,fee schedule,,,26.07,,,fee schedule,,,31.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOTYPE IA HIV 1 REV T NS,3072808,CDM,306,RC,87901,CPT,,,,,,inpatient,facility,,,773,324.66,657.05,742.08,,657.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.51,,,percent of total billed charges,,,,,,,,,695.7,,,percent of total billed charges,,,742.08,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,718.89,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOTYPE IA HIV 1 REV T NS,3072808,CDM,306,RC,87901,CPT,,,,,,outpatient,facility,,,773,324.66,208.71,742.08,,657.05,,,percent of total billed charges,,,208.71,,,percent of total billed charges,,,531.82,,,percent of total billed charges,,,520.23,,,percent of total billed charges,,,653.18,,,percent of total billed charges,,,257.45,,,fee schedule,,,672.51,,,percent of total billed charges,,,672.51,,,percent of total billed charges,,,657.05,,,percent of total billed charges,,,742.08,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,262.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",695.7,,,percent of total billed charges,,,257.45,,,fee schedule,,,718.89,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,373.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",347.56,,,fee schedule,,,228.62,,,fee schedule,,,228.62,,,fee schedule,,,224.05,,,fee schedule,,,257.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",603.71,,,percent of total billed charges,,,703.43,,,percent of total billed charges,,,257.45,,,fee schedule,,,257.45,,,fee schedule,,,315.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GASTRIN,3073004,CDM,301,RC,82941,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GASTRIN,3073004,CDM,301,RC,82941,CPT,,,,,,outpatient,facility,,,58,24.36,15.35,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,17.63,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,17.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,17.63,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,25.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.8,,,fee schedule,,,15.66,,,fee schedule,,,15.66,,,fee schedule,,,15.35,,,fee schedule,,,17.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,17.63,,,fee schedule,,,17.63,,,fee schedule,,,21.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENTAMICIN PEAK,3073038,CDM,301,RC,80170,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENTAMICIN PEAK,3073038,CDM,301,RC,80170,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.38,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.38,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.11,,,fee schedule,,,14.55,,,fee schedule,,,14.55,,,fee schedule,,,14.26,,,fee schedule,,,16.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.38,,,fee schedule,,,16.38,,,fee schedule,,,20.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENTAMICIN RANDOM,3073046,CDM,301,RC,80170,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENTAMICIN RANDOM,3073046,CDM,301,RC,80170,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.38,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.38,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.11,,,fee schedule,,,14.55,,,fee schedule,,,14.55,,,fee schedule,,,14.26,,,fee schedule,,,16.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.38,,,fee schedule,,,16.38,,,fee schedule,,,20.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENTAMICIN TROUGH,3073053,CDM,301,RC,80170,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENTAMICIN TROUGH,3073053,CDM,301,RC,80170,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.38,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.38,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.11,,,fee schedule,,,14.55,,,fee schedule,,,14.55,,,fee schedule,,,14.26,,,fee schedule,,,16.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.38,,,fee schedule,,,16.38,,,fee schedule,,,20.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRANSFERASE GAMMA GLUTAMYL,3073061,CDM,301,RC,82977,CPT,,,,,,inpatient,facility,,,22,9.24,18.7,21.12,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERASE GAMMA GLUTAMYL,3073061,CDM,301,RC,82977,CPT,,,,,,outpatient,facility,,,22,9.24,5.94,21.12,,18.7,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,14.81,,,percent of total billed charges,,,18.59,,,percent of total billed charges,,,7.2,,,fee schedule,,,19.14,,,percent of total billed charges,,,19.14,,,percent of total billed charges,,,18.7,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,7.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.8,,,percent of total billed charges,,,7.2,,,fee schedule,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,10.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.72,,,fee schedule,,,6.39,,,fee schedule,,,6.39,,,fee schedule,,,6.26,,,fee schedule,,,7.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",17.18,,,percent of total billed charges,,,20.02,,,percent of total billed charges,,,7.2,,,fee schedule,,,7.2,,,fee schedule,,,8.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCAGON,3073079,CDM,301,RC,82943,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCAGON,3073079,CDM,301,RC,82943,CPT,,,,,,outpatient,facility,,,67,28.14,12.44,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,14.29,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,14.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,14.29,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,20.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.29,,,fee schedule,,,12.69,,,fee schedule,,,12.69,,,fee schedule,,,12.44,,,fee schedule,,,14.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,14.29,,,fee schedule,,,14.29,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE QN BLOOD,3073103,CDM,301,RC,82947,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE QN BLOOD,3073103,CDM,301,RC,82947,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,12,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.93,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.93,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE QN BLOOD FASTING,3073111,CDM,301,RC,82947,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE QN BLOOD FASTING,3073111,CDM,301,RC,82947,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,12,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.93,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.93,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE QN BLOOD RANDOM,3073129,CDM,301,RC,82947,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE QN BLOOD RANDOM,3073129,CDM,301,RC,82947,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,12,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.93,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.93,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE FLUID BODY,3073137,CDM,301,RC,82945,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE FLUID BODY,3073137,CDM,301,RC,82945,CPT,,,,,,outpatient,facility,,,56,23.52,3.42,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,3.93,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,3.93,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,4.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE CSF,3073152,CDM,301,RC,82945,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE CSF,3073152,CDM,301,RC,82945,CPT,,,,,,outpatient,facility,,,55,23.1,3.42,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,3.93,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,3.93,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,4.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE POST DOSE,3073160,CDM,301,RC,82950,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE POST DOSE,3073160,CDM,301,RC,82950,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.75,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.75,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.41,,,fee schedule,,,4.22,,,fee schedule,,,4.22,,,fee schedule,,,4.14,,,fee schedule,,,4.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.75,,,fee schedule,,,4.75,,,fee schedule,,,5.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE TOLERANCE SPEC 1ST 3,3073186,CDM,301,RC,82951,CPT,,,,,,inpatient,facility,,,39,16.38,33.15,37.44,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.93,,,percent of total billed charges,,,,,,,,,35.1,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE TOLERANCE SPEC 1ST 3,3073186,CDM,301,RC,82951,CPT,,,,,,outpatient,facility,,,39,16.38,10.53,37.44,,33.15,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,32.95,,,percent of total billed charges,,,12.87,,,fee schedule,,,33.93,,,percent of total billed charges,,,33.93,,,percent of total billed charges,,,33.15,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,13.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.1,,,percent of total billed charges,,,12.87,,,fee schedule,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,18.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.37,,,fee schedule,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,11.2,,,fee schedule,,,12.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",30.46,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,12.87,,,fee schedule,,,12.87,,,fee schedule,,,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE TOLERANCE SPEC EA ADDL,3073194,CDM,301,RC,82952,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE TOLERANCE SPEC EA ADDL,3073194,CDM,301,RC,82952,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,11.52,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.92,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.92,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.29,,,fee schedule,,,3.48,,,fee schedule,,,3.48,,,fee schedule,,,3.41,,,fee schedule,,,3.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.92,,,fee schedule,,,3.92,,,fee schedule,,,3.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE URINE RANDOM,3073202,CDM,301,RC,82945,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE URINE RANDOM,3073202,CDM,301,RC,82945,CPT,,,,,,outpatient,facility,,,55,23.1,3.42,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,3.93,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,3.93,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,4.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE URINE TIMED,3073210,CDM,301,RC,82945,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE URINE TIMED,3073210,CDM,301,RC,82945,CPT,,,,,,outpatient,facility,,,56,23.52,3.42,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,3.93,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,3.93,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,4.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT GLYCATED,3073236,CDM,301,RC,82985,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT GLYCATED,3073236,CDM,301,RC,82985,CPT,,,,,,outpatient,facility,,,53,22.26,14.31,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,16.76,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,17.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,16.76,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,24.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.63,,,fee schedule,,,14.88,,,fee schedule,,,14.88,,,fee schedule,,,14.58,,,fee schedule,,,16.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,16.76,,,fee schedule,,,16.76,,,fee schedule,,,18.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HORMONE HUMAN GROWTH,3073251,CDM,301,RC,83003,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HORMONE HUMAN GROWTH,3073251,CDM,301,RC,83003,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.67,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.67,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,fee schedule,,,14.8,,,fee schedule,,,14.8,,,fee schedule,,,14.5,,,fee schedule,,,16.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.67,,,fee schedule,,,16.67,,,fee schedule,,,20.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB H PYLORI UREASE NONRADIOACT,3073269,CDM,301,RC,83013,CPT,,,,,,inpatient,facility,,,203,85.26,172.55,194.88,,172.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,176.61,,,percent of total billed charges,,,,,,,,,182.7,,,percent of total billed charges,,,194.88,,,percent of total billed charges,,,192.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,188.79,,,percent of total billed charges,,,192.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB H PYLORI UREASE NONRADIOACT,3073269,CDM,301,RC,83013,CPT,,,,,,outpatient,facility,,,203,85.26,54.81,194.88,,172.55,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,139.66,,,percent of total billed charges,,,136.62,,,percent of total billed charges,,,171.53,,,percent of total billed charges,,,67.36,,,fee schedule,,,176.61,,,percent of total billed charges,,,176.61,,,percent of total billed charges,,,172.55,,,percent of total billed charges,,,194.88,,,percent of total billed charges,,,192.85,,,percent of total billed charges,,,68.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",182.7,,,percent of total billed charges,,,67.36,,,fee schedule,,,188.79,,,percent of total billed charges,,,192.85,,,percent of total billed charges,,,97.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90.94,,,fee schedule,,,59.82,,,fee schedule,,,59.82,,,fee schedule,,,58.62,,,fee schedule,,,67.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",158.54,,,percent of total billed charges,,,184.73,,,percent of total billed charges,,,67.36,,,fee schedule,,,67.36,,,fee schedule,,,82.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HALOPERIDOL,3073277,CDM,301,RC,80173,CPT,,,,,,inpatient,facility,,,99,41.58,84.15,95.04,,84.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.13,,,percent of total billed charges,,,,,,,,,89.1,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.07,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HALOPERIDOL,3073277,CDM,301,RC,80173,CPT,,,,,,outpatient,facility,,,99,41.58,13.73,95.04,,84.15,,,percent of total billed charges,,,26.73,,,percent of total billed charges,,,68.11,,,percent of total billed charges,,,66.63,,,percent of total billed charges,,,83.66,,,percent of total billed charges,,,15.78,,,fee schedule,,,86.13,,,percent of total billed charges,,,86.13,,,percent of total billed charges,,,84.15,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,16.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",89.1,,,percent of total billed charges,,,15.78,,,fee schedule,,,92.07,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,22.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.3,,,fee schedule,,,14.01,,,fee schedule,,,14.01,,,fee schedule,,,13.73,,,fee schedule,,,15.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",77.32,,,percent of total billed charges,,,90.09,,,percent of total billed charges,,,15.78,,,fee schedule,,,15.78,,,fee schedule,,,17.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HAPTOGLOBIN QN,3073285,CDM,301,RC,83010,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HAPTOGLOBIN QN,3073285,CDM,301,RC,83010,CPT,,,,,,outpatient,facility,,,53,22.26,10.95,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,12.58,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,12.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,12.58,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,18.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.98,,,fee schedule,,,11.17,,,fee schedule,,,11.17,,,fee schedule,,,10.95,,,fee schedule,,,12.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,12.58,,,fee schedule,,,12.58,,,fee schedule,,,15.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HCG QL,3073293,CDM,301,RC,84703,CPT,,,,,,inpatient,facility,,,23,9.66,19.55,22.08,,19.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.01,,,percent of total billed charges,,,,,,,,,20.7,,,percent of total billed charges,,,22.08,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.39,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HCG QL,3073293,CDM,301,RC,84703,CPT,,,,,,outpatient,facility,,,23,9.66,6.21,22.08,,19.55,,,percent of total billed charges,,,6.21,,,percent of total billed charges,,,15.82,,,percent of total billed charges,,,15.48,,,percent of total billed charges,,,19.43,,,percent of total billed charges,,,7.52,,,fee schedule,,,20.01,,,percent of total billed charges,,,20.01,,,percent of total billed charges,,,19.55,,,percent of total billed charges,,,22.08,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,7.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.7,,,percent of total billed charges,,,7.52,,,fee schedule,,,21.39,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,10.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.15,,,fee schedule,,,6.68,,,fee schedule,,,6.68,,,fee schedule,,,6.55,,,fee schedule,,,7.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",17.96,,,percent of total billed charges,,,20.93,,,percent of total billed charges,,,7.52,,,fee schedule,,,7.52,,,fee schedule,,,9.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HCG QN,3073301,CDM,301,RC,84702,CPT,,,,,,inpatient,facility,,,46,19.32,39.1,44.16,,39.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.02,,,percent of total billed charges,,,,,,,,,41.4,,,percent of total billed charges,,,44.16,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.78,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HCG QN,3073301,CDM,301,RC,84702,CPT,,,,,,outpatient,facility,,,46,19.32,12.42,44.16,,39.1,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,30.96,,,percent of total billed charges,,,38.87,,,percent of total billed charges,,,15.05,,,fee schedule,,,40.02,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,39.1,,,percent of total billed charges,,,44.16,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,15.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.4,,,percent of total billed charges,,,15.05,,,fee schedule,,,42.78,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.32,,,fee schedule,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,13.09,,,fee schedule,,,15.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",35.93,,,percent of total billed charges,,,41.86,,,percent of total billed charges,,,15.05,,,fee schedule,,,15.05,,,fee schedule,,,18.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HCG TUMOR MARKER QN,3073319,CDM,301,RC,84702,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HCG TUMOR MARKER QN,3073319,CDM,301,RC,84702,CPT,,,,,,outpatient,facility,,,57,23.94,13.09,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,15.05,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,15.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,15.05,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.32,,,fee schedule,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,13.09,,,fee schedule,,,15.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,15.05,,,fee schedule,,,15.05,,,fee schedule,,,18.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEAVY METAL QN EA,3073400,CDM,301,RC,83018,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEAVY METAL QN EA,3073400,CDM,301,RC,83018,CPT,,,,,,outpatient,facility,,,106,44.52,19.11,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,21.96,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,22.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,21.96,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,31.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.65,,,fee schedule,,,19.5,,,fee schedule,,,19.5,,,fee schedule,,,19.11,,,fee schedule,,,21.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,21.96,,,fee schedule,,,21.96,,,fee schedule,,,26.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOGLOBIN FETAL QL,3073541,CDM,301,RC,83033,CPT,,,,,,inpatient,facility,,,417,175.14,354.45,400.32,,354.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,362.79,,,percent of total billed charges,,,,,,,,,375.3,,,percent of total billed charges,,,400.32,,,percent of total billed charges,,,396.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,387.81,,,percent of total billed charges,,,396.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOGLOBIN FETAL QL,3073541,CDM,301,RC,83033,CPT,,,,,,outpatient,facility,,,417,175.14,6.96,400.32,,354.45,,,percent of total billed charges,,,112.59,,,percent of total billed charges,,,286.9,,,percent of total billed charges,,,280.64,,,percent of total billed charges,,,352.37,,,percent of total billed charges,,,8,,,fee schedule,,,362.79,,,percent of total billed charges,,,362.79,,,percent of total billed charges,,,354.45,,,percent of total billed charges,,,400.32,,,percent of total billed charges,,,396.15,,,percent of total billed charges,,,8.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",375.3,,,percent of total billed charges,,,8,,,fee schedule,,,387.81,,,percent of total billed charges,,,396.15,,,percent of total billed charges,,,11.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,fee schedule,,,7.1,,,fee schedule,,,7.1,,,fee schedule,,,6.96,,,fee schedule,,,8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",325.68,,,percent of total billed charges,,,379.47,,,percent of total billed charges,,,8,,,fee schedule,,,8,,,fee schedule,,,7.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOGLOBIN PLASMA,3073558,CDM,301,RC,83051,CPT,,,,,,inpatient,facility,,,22,9.24,18.7,21.12,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOGLOBIN PLASMA,3073558,CDM,301,RC,83051,CPT,,,,,,outpatient,facility,,,22,9.24,5.94,21.12,,18.7,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,14.81,,,percent of total billed charges,,,18.59,,,percent of total billed charges,,,7.31,,,fee schedule,,,19.14,,,percent of total billed charges,,,19.14,,,percent of total billed charges,,,18.7,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,7.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.8,,,percent of total billed charges,,,7.31,,,fee schedule,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,10.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.87,,,fee schedule,,,6.49,,,fee schedule,,,6.49,,,fee schedule,,,6.36,,,fee schedule,,,7.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",17.18,,,percent of total billed charges,,,20.02,,,percent of total billed charges,,,7.31,,,fee schedule,,,7.31,,,fee schedule,,,8.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOSIDERIN QL,3073574,CDM,301,RC,83070,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOSIDERIN QL,3073574,CDM,301,RC,83070,CPT,,,,,,outpatient,facility,,,52,21.84,2.9,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,4.75,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,4.75,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,6.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.41,,,fee schedule,,,4.22,,,fee schedule,,,4.22,,,fee schedule,,,4.14,,,fee schedule,,,4.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,4.75,,,fee schedule,,,4.75,,,fee schedule,,,2.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL FUNCTION HEPATIC,3073582,CDM,301,RC,80076,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL FUNCTION HEPATIC,3073582,CDM,301,RC,80076,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.17,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.17,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.03,,,fee schedule,,,7.25,,,fee schedule,,,7.25,,,fee schedule,,,7.11,,,fee schedule,,,8.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.17,,,fee schedule,,,8.17,,,fee schedule,,,9.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOGLOBIN A1C,3073624,CDM,301,RC,83036,CPT,,,,,,inpatient,facility,,,30,12.6,25.5,28.8,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,27,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOGLOBIN A1C,3073624,CDM,301,RC,83036,CPT,,,,,,outpatient,facility,,,30,12.6,8.1,28.8,,25.5,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,20.64,,,percent of total billed charges,,,20.19,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,9.71,,,fee schedule,,,26.1,,,percent of total billed charges,,,26.1,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,9.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27,,,percent of total billed charges,,,9.71,,,fee schedule,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,14.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.11,,,fee schedule,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,8.45,,,fee schedule,,,9.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",23.43,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,9.71,,,fee schedule,,,9.71,,,fee schedule,,,9.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HISTAMINE,3073632,CDM,301,RC,83088,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HISTAMINE,3073632,CDM,301,RC,83088,CPT,,,,,,outpatient,facility,,,90,37.8,24.3,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,29.53,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,30.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,29.53,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,42.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.87,,,fee schedule,,,26.22,,,fee schedule,,,26.22,,,fee schedule,,,25.7,,,fee schedule,,,29.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,29.53,,,fee schedule,,,29.53,,,fee schedule,,,35.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HOMOCYSTEINE SERUM,3073657,CDM,301,RC,83090,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HOMOCYSTEINE SERUM,3073657,CDM,301,RC,83090,CPT,,,,,,outpatient,facility,,,58,24.36,15.59,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,17.92,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,18.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,17.92,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,25.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.19,,,fee schedule,,,15.91,,,fee schedule,,,15.91,,,fee schedule,,,15.59,,,fee schedule,,,17.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,17.92,,,fee schedule,,,17.92,,,fee schedule,,,20.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID HOMOVANILLIC,3073665,CDM,301,RC,83150,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID HOMOVANILLIC,3073665,CDM,301,RC,83150,CPT,,,,,,outpatient,facility,,,68,28.56,10.55,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,22.41,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,22.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,22.41,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,32.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.25,,,fee schedule,,,19.9,,,fee schedule,,,19.9,,,fee schedule,,,19.5,,,fee schedule,,,22.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,22.41,,,fee schedule,,,22.41,,,fee schedule,,,10.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID HYDROXYINDOLACETIC 5,3073681,CDM,301,RC,83497,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID HYDROXYINDOLACETIC 5,3073681,CDM,301,RC,83497,CPT,,,,,,outpatient,facility,,,61,25.62,4.17,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,12.9,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,13.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,12.9,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,18.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.42,,,fee schedule,,,11.46,,,fee schedule,,,11.46,,,fee schedule,,,11.23,,,fee schedule,,,12.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,12.9,,,fee schedule,,,12.9,,,fee schedule,,,4.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HYDROXYPROGESTERONE 17 D NS,3073699,CDM,301,RC,83498,CPT,,,,,,inpatient,facility,,,82,34.44,69.7,78.72,,69.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.34,,,percent of total billed charges,,,,,,,,,73.8,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HYDROXYPROGESTERONE 17 D NS,3073699,CDM,301,RC,83498,CPT,,,,,,outpatient,facility,,,82,34.44,22.14,78.72,,69.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,55.19,,,percent of total billed charges,,,69.29,,,percent of total billed charges,,,27.17,,,fee schedule,,,71.34,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,69.7,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,27.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",73.8,,,percent of total billed charges,,,27.17,,,fee schedule,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,39.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.68,,,fee schedule,,,24.13,,,fee schedule,,,24.13,,,fee schedule,,,23.65,,,fee schedule,,,27.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.04,,,percent of total billed charges,,,74.62,,,percent of total billed charges,,,27.17,,,fee schedule,,,27.17,,,fee schedule,,,33.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HYDROXYPROLINE FREE,3073707,CDM,301,RC,83500,CPT,,,,,,inpatient,facility,,,112,47.04,95.2,107.52,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HYDROXYPROLINE FREE,3073707,CDM,301,RC,83500,CPT,,,,,,outpatient,facility,,,112,47.04,19.71,107.52,,95.2,,,percent of total billed charges,,,30.24,,,percent of total billed charges,,,77.06,,,percent of total billed charges,,,75.38,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,22.65,,,fee schedule,,,97.44,,,percent of total billed charges,,,97.44,,,percent of total billed charges,,,95.2,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,23.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.8,,,percent of total billed charges,,,22.65,,,fee schedule,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,32.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.58,,,fee schedule,,,20.11,,,fee schedule,,,20.11,,,fee schedule,,,19.71,,,fee schedule,,,22.65,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",87.47,,,percent of total billed charges,,,101.92,,,percent of total billed charges,,,22.65,,,fee schedule,,,22.65,,,fee schedule,,,27.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG IGA IGD IGG IGM SERUM EA,3073749,CDM,301,RC,82784,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG IGA IGD IGG IGM SERUM EA,3073749,CDM,301,RC,82784,CPT,,,,,,outpatient,facility,,,52,21.84,8.09,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,9.3,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,9.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,9.3,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,13.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.56,,,fee schedule,,,8.26,,,fee schedule,,,8.26,,,fee schedule,,,8.09,,,fee schedule,,,9.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,9.3,,,fee schedule,,,9.3,,,fee schedule,,,11.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS QL SEMI QN NS,3073764,CDM,301,RC,83516,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS QL SEMI QN NS,3073764,CDM,301,RC,83516,CPT,,,,,,outpatient,facility,,,57,23.94,10.04,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,11.53,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,11.53,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM SGL STEP QL SEMI QN NS,3073772,CDM,301,RC,83518,CPT,,,,,,inpatient,facility,,,485,203.7,412.25,465.6,,412.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,421.95,,,percent of total billed charges,,,,,,,,,436.5,,,percent of total billed charges,,,465.6,,,percent of total billed charges,,,460.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.05,,,percent of total billed charges,,,460.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM SGL STEP QL SEMI QN NS,3073772,CDM,301,RC,83518,CPT,,,,,,outpatient,facility,,,485,203.7,8.39,465.6,,412.25,,,percent of total billed charges,,,130.95,,,percent of total billed charges,,,333.68,,,percent of total billed charges,,,326.4,,,percent of total billed charges,,,409.82,,,percent of total billed charges,,,9.64,,,fee schedule,,,421.95,,,percent of total billed charges,,,421.95,,,percent of total billed charges,,,412.25,,,percent of total billed charges,,,465.6,,,percent of total billed charges,,,460.75,,,percent of total billed charges,,,9.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",436.5,,,percent of total billed charges,,,9.64,,,fee schedule,,,451.05,,,percent of total billed charges,,,460.75,,,percent of total billed charges,,,13.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.01,,,fee schedule,,,8.56,,,fee schedule,,,8.56,,,fee schedule,,,8.39,,,fee schedule,,,9.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",378.79,,,percent of total billed charges,,,441.35,,,percent of total billed charges,,,9.64,,,fee schedule,,,9.64,,,fee schedule,,,10.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS GLIADIN IGA QL,3073780,CDM,302,RC,86258,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS GLIADIN IGA QL,3073780,CDM,302,RC,86258,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.05,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,11.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS GLIADIN IGG QL,3073798,CDM,302,RC,86258,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS GLIADIN IGG QL,3073798,CDM,302,RC,86258,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.05,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,11.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB NEURONAL QN,3073814,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB NEURONAL QN,3073814,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.27,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.27,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM ANALYTE OTHER QN,3073830,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM ANALYTE OTHER QN,3073830,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,80,33.6,15.03,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,17.27,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,17.27,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM RIA QN,3073863,CDM,301,RC,83519,CPT,,,,,,inpatient,facility,,,94,39.48,79.9,90.24,,79.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.78,,,percent of total billed charges,,,,,,,,,84.6,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM RIA QN,3073863,CDM,301,RC,83519,CPT,,,,,,outpatient,facility,,,94,39.48,16.01,90.24,,79.9,,,percent of total billed charges,,,25.38,,,percent of total billed charges,,,64.67,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,79.43,,,percent of total billed charges,,,18.4,,,fee schedule,,,81.78,,,percent of total billed charges,,,81.78,,,percent of total billed charges,,,79.9,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,18.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.6,,,percent of total billed charges,,,18.4,,,fee schedule,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,26.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.84,,,fee schedule,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,16.01,,,fee schedule,,,18.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",73.41,,,percent of total billed charges,,,85.54,,,percent of total billed charges,,,18.4,,,fee schedule,,,18.4,,,fee schedule,,,16.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM RIA TRYPSIN QN,3073871,CDM,301,RC,83519,CPT,,,,,,inpatient,facility,,,82,34.44,69.7,78.72,,69.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.34,,,percent of total billed charges,,,,,,,,,73.8,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM RIA TRYPSIN QN,3073871,CDM,301,RC,83519,CPT,,,,,,outpatient,facility,,,82,34.44,16.01,78.72,,69.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,55.19,,,percent of total billed charges,,,69.29,,,percent of total billed charges,,,18.4,,,fee schedule,,,71.34,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,69.7,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,18.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",73.8,,,percent of total billed charges,,,18.4,,,fee schedule,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,26.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.84,,,fee schedule,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,16.01,,,fee schedule,,,18.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.04,,,percent of total billed charges,,,74.62,,,percent of total billed charges,,,18.4,,,fee schedule,,,18.4,,,fee schedule,,,16.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG SUBCLASSES EA,3073897,CDM,301,RC,82787,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG SUBCLASSES EA,3073897,CDM,301,RC,82787,CPT,,,,,,outpatient,facility,,,59,24.78,5.65,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,8.02,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,8.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,8.02,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.83,,,fee schedule,,,7.12,,,fee schedule,,,7.12,,,fee schedule,,,6.98,,,fee schedule,,,8.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,8.02,,,fee schedule,,,8.02,,,fee schedule,,,5.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INSULIN FREE,3073905,CDM,301,RC,83527,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INSULIN FREE,3073905,CDM,301,RC,83527,CPT,,,,,,outpatient,facility,,,63,26.46,11.27,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,12.95,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,13.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,12.95,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,18.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.48,,,fee schedule,,,11.5,,,fee schedule,,,11.5,,,fee schedule,,,11.27,,,fee schedule,,,12.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,12.95,,,fee schedule,,,12.95,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INSULIN TOTAL,3073913,CDM,301,RC,83525,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INSULIN TOTAL,3073913,CDM,301,RC,83525,CPT,,,,,,outpatient,facility,,,57,23.94,6.99,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,11.43,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,11.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,11.43,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,16.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.43,,,fee schedule,,,10.15,,,fee schedule,,,10.15,,,fee schedule,,,9.95,,,fee schedule,,,11.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IRON,3073921,CDM,301,RC,83540,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IRON,3073921,CDM,301,RC,83540,CPT,,,,,,outpatient,facility,,,20,8.4,5.4,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.47,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.47,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,7.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CAPACITY IRON BINDING,3073939,CDM,301,RC,83550,CPT,,,,,,inpatient,facility,,,27,11.34,22.95,25.92,,22.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,percent of total billed charges,,,,,,,,,24.3,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.11,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CAPACITY IRON BINDING,3073939,CDM,301,RC,83550,CPT,,,,,,outpatient,facility,,,27,11.34,7.29,25.92,,22.95,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,18.58,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,22.81,,,percent of total billed charges,,,8.74,,,fee schedule,,,23.49,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,8.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.3,,,percent of total billed charges,,,8.74,,,fee schedule,,,25.11,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,12.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.8,,,fee schedule,,,7.76,,,fee schedule,,,7.76,,,fee schedule,,,7.6,,,fee schedule,,,8.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",21.09,,,percent of total billed charges,,,24.57,,,percent of total billed charges,,,8.74,,,fee schedule,,,8.74,,,fee schedule,,,10.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LACTATE LACTIC ACID,3074036,CDM,301,RC,83605,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LACTATE LACTIC ACID,3074036,CDM,301,RC,83605,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.57,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.57,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.62,,,fee schedule,,,10.27,,,fee schedule,,,10.27,,,fee schedule,,,10.06,,,fee schedule,,,11.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.57,,,fee schedule,,,11.57,,,fee schedule,,,13.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LAMOTRIGINE,3074077,CDM,301,RC,80175,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LAMOTRIGINE,3074077,CDM,301,RC,80175,CPT,,,,,,outpatient,facility,,,61,25.62,11.53,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,13.25,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,13.25,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LDH,3074085,CDM,301,RC,83615,CPT,,,,,,inpatient,facility,,,19,7.98,16.15,18.24,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.53,,,percent of total billed charges,,,,,,,,,17.1,,,percent of total billed charges,,,18.24,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.67,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LDH,3074085,CDM,301,RC,83615,CPT,,,,,,outpatient,facility,,,19,7.98,5.13,18.24,,16.15,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,13.07,,,percent of total billed charges,,,12.79,,,percent of total billed charges,,,16.05,,,percent of total billed charges,,,6.04,,,fee schedule,,,16.53,,,percent of total billed charges,,,16.53,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,18.24,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,6.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.1,,,percent of total billed charges,,,6.04,,,fee schedule,,,17.67,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,8.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.15,,,fee schedule,,,5.36,,,fee schedule,,,5.36,,,fee schedule,,,5.25,,,fee schedule,,,6.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.84,,,percent of total billed charges,,,17.29,,,percent of total billed charges,,,6.04,,,fee schedule,,,6.04,,,fee schedule,,,7.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LDH FLUID BODY,3074093,CDM,301,RC,83615,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LDH FLUID BODY,3074093,CDM,301,RC,83615,CPT,,,,,,outpatient,facility,,,57,23.94,5.25,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,6.04,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,6.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,6.04,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,8.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.15,,,fee schedule,,,5.36,,,fee schedule,,,5.36,,,fee schedule,,,5.25,,,fee schedule,,,6.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,6.04,,,fee schedule,,,6.04,,,fee schedule,,,7.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LDH CSF,3074101,CDM,301,RC,83615,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LDH CSF,3074101,CDM,301,RC,83615,CPT,,,,,,outpatient,facility,,,56,23.52,5.25,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.04,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,6.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,6.04,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,8.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.15,,,fee schedule,,,5.36,,,fee schedule,,,5.36,,,fee schedule,,,5.25,,,fee schedule,,,6.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,6.04,,,fee schedule,,,6.04,,,fee schedule,,,7.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LDH ISOENZYMES,3074119,CDM,301,RC,83625,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LDH ISOENZYMES,3074119,CDM,301,RC,83625,CPT,,,,,,outpatient,facility,,,59,24.78,11.13,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,12.79,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,13.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,12.79,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,18.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.27,,,fee schedule,,,11.36,,,fee schedule,,,11.36,,,fee schedule,,,11.13,,,fee schedule,,,12.79,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,12.79,,,fee schedule,,,12.79,,,fee schedule,,,15.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LEAD BLOOD,3074127,CDM,301,RC,83655,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LEAD BLOOD,3074127,CDM,301,RC,83655,CPT,,,,,,outpatient,facility,,,59,24.78,10.54,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,12.11,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,12.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,12.11,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,17.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.35,,,fee schedule,,,10.75,,,fee schedule,,,10.75,,,fee schedule,,,10.54,,,fee schedule,,,12.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,12.11,,,fee schedule,,,12.11,,,fee schedule,,,14.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LEAD NON BLOOD,3074135,CDM,301,RC,83655,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LEAD NON BLOOD,3074135,CDM,301,RC,83655,CPT,,,,,,outpatient,facility,,,79,33.18,10.54,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,12.11,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,12.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,12.11,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,17.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.35,,,fee schedule,,,10.75,,,fee schedule,,,10.75,,,fee schedule,,,10.54,,,fee schedule,,,12.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,12.11,,,fee schedule,,,12.11,,,fee schedule,,,14.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIDOCAINE,3074168,CDM,301,RC,80176,CPT,,,,,,inpatient,facility,,,45,18.9,38.25,43.2,,38.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.15,,,percent of total billed charges,,,,,,,,,40.5,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.85,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIDOCAINE,3074168,CDM,301,RC,80176,CPT,,,,,,outpatient,facility,,,45,18.9,12.15,43.2,,38.25,,,percent of total billed charges,,,12.15,,,percent of total billed charges,,,30.96,,,percent of total billed charges,,,30.28,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,14.69,,,fee schedule,,,39.15,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,,38.25,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,14.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",40.5,,,percent of total billed charges,,,14.69,,,fee schedule,,,41.85,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,21.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.83,,,fee schedule,,,13.04,,,fee schedule,,,13.04,,,fee schedule,,,12.78,,,fee schedule,,,14.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",35.14,,,percent of total billed charges,,,40.95,,,percent of total billed charges,,,14.69,,,fee schedule,,,14.69,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPASE,3074176,CDM,301,RC,83690,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPASE,3074176,CDM,301,RC,83690,CPT,,,,,,outpatient,facility,,,21,8.82,5.67,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.89,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,7.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.89,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,9.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.3,,,fee schedule,,,6.12,,,fee schedule,,,6.12,,,fee schedule,,,6,,,fee schedule,,,6.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.89,,,fee schedule,,,6.89,,,fee schedule,,,8.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPASE FLUID BODY,3074184,CDM,301,RC,83690,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPASE FLUID BODY,3074184,CDM,301,RC,83690,CPT,,,,,,outpatient,facility,,,52,21.84,6,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,6.89,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,7.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,6.89,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,9.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.3,,,fee schedule,,,6.12,,,fee schedule,,,6.12,,,fee schedule,,,6,,,fee schedule,,,6.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.89,,,fee schedule,,,6.89,,,fee schedule,,,8.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL LIPID,3074192,CDM,301,RC,80061,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL LIPID,3074192,CDM,301,RC,80061,CPT,,,,,,outpatient,facility,,,54,22.68,11.65,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,13.39,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,13.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,13.39,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,19.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.08,,,fee schedule,,,11.89,,,fee schedule,,,11.89,,,fee schedule,,,11.65,,,fee schedule,,,13.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,13.39,,,fee schedule,,,13.39,,,fee schedule,,,13.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN A,3074200,CDM,301,RC,83695,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN A,3074200,CDM,301,RC,83695,CPT,,,,,,outpatient,facility,,,57,23.94,12.47,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,14.32,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,14.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,14.32,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,20.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.33,,,fee schedule,,,12.72,,,fee schedule,,,12.72,,,fee schedule,,,12.47,,,fee schedule,,,14.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN ELECTRO,3074218,CDM,301,RC,83700,CPT,,,,,,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN ELECTRO,3074218,CDM,301,RC,83700,CPT,,,,,,outpatient,facility,,,103,43.26,9.8,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,11.26,,,fee schedule,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,11.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",92.7,,,percent of total billed charges,,,11.26,,,fee schedule,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,16.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.2,,,fee schedule,,,10,,,fee schedule,,,10,,,fee schedule,,,9.8,,,fee schedule,,,11.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,11.26,,,fee schedule,,,11.26,,,fee schedule,,,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN FRCTN HR,3074226,CDM,301,RC,83701,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN FRCTN HR,3074226,CDM,301,RC,83701,CPT,,,,,,outpatient,facility,,,102,42.84,14.02,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,33.86,,,fee schedule,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,34.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",91.8,,,percent of total billed charges,,,33.86,,,fee schedule,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,49.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.71,,,fee schedule,,,30.07,,,fee schedule,,,30.07,,,fee schedule,,,29.47,,,fee schedule,,,33.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,33.86,,,fee schedule,,,33.86,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LITHIUM,3074234,CDM,301,RC,80178,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LITHIUM,3074234,CDM,301,RC,80178,CPT,,,,,,outpatient,facility,,,52,21.84,5.75,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,6.61,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,6.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,6.61,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,9.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.92,,,fee schedule,,,5.87,,,fee schedule,,,5.87,,,fee schedule,,,5.75,,,fee schedule,,,6.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.61,,,fee schedule,,,6.61,,,fee schedule,,,6.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GONADOTROPIN LH,3074259,CDM,301,RC,83002,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GONADOTROPIN LH,3074259,CDM,301,RC,83002,CPT,,,,,,outpatient,facility,,,58,24.36,15.66,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,18.52,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,18.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,18.52,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,26.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25,,,fee schedule,,,16.45,,,fee schedule,,,16.45,,,fee schedule,,,16.12,,,fee schedule,,,18.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,18.52,,,fee schedule,,,18.52,,,fee schedule,,,22.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MAGNESIUM,3074283,CDM,301,RC,83735,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MAGNESIUM,3074283,CDM,301,RC,83735,CPT,,,,,,outpatient,facility,,,21,8.82,5.67,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.7,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,6.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.7,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,9.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.05,,,fee schedule,,,5.95,,,fee schedule,,,5.95,,,fee schedule,,,5.83,,,fee schedule,,,6.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MAGNESIUM STOOL,3074291,CDM,301,RC,83735,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MAGNESIUM STOOL,3074291,CDM,301,RC,83735,CPT,,,,,,outpatient,facility,,,21,8.82,5.67,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.7,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,6.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.7,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,9.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.05,,,fee schedule,,,5.95,,,fee schedule,,,5.95,,,fee schedule,,,5.83,,,fee schedule,,,6.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MAGNESIUM URINE,3074309,CDM,301,RC,83735,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MAGNESIUM URINE,3074309,CDM,301,RC,83735,CPT,,,,,,outpatient,facility,,,52,21.84,5.83,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,6.7,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,6.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,6.7,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,9.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.05,,,fee schedule,,,5.95,,,fee schedule,,,5.95,,,fee schedule,,,5.83,,,fee schedule,,,6.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MANGANESE,3074325,CDM,301,RC,83785,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MANGANESE,3074325,CDM,301,RC,83785,CPT,,,,,,outpatient,facility,,,80,33.6,21.6,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,26.65,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,27.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,26.65,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,38.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.98,,,fee schedule,,,23.67,,,fee schedule,,,23.67,,,fee schedule,,,23.2,,,fee schedule,,,26.65,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,26.65,,,fee schedule,,,26.65,,,fee schedule,,,30.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MERCURY BLOOD QN,3074390,CDM,301,RC,83825,CPT,,,,,,inpatient,facility,,,49,20.58,41.65,47.04,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.63,,,percent of total billed charges,,,,,,,,,44.1,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MERCURY BLOOD QN,3074390,CDM,301,RC,83825,CPT,,,,,,outpatient,facility,,,49,20.58,13.23,47.04,,41.65,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,33.71,,,percent of total billed charges,,,32.98,,,percent of total billed charges,,,41.41,,,percent of total billed charges,,,16.26,,,fee schedule,,,42.63,,,percent of total billed charges,,,42.63,,,percent of total billed charges,,,41.65,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,16.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",44.1,,,percent of total billed charges,,,16.26,,,fee schedule,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,23.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.95,,,fee schedule,,,14.44,,,fee schedule,,,14.44,,,fee schedule,,,14.15,,,fee schedule,,,16.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",38.27,,,percent of total billed charges,,,44.59,,,percent of total billed charges,,,16.26,,,fee schedule,,,16.26,,,fee schedule,,,19.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MERCURY NON BLOOD QN,3074408,CDM,301,RC,83825,CPT,,,,,,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MERCURY NON BLOOD QN,3074408,CDM,301,RC,83825,CPT,,,,,,outpatient,facility,,,88,36.96,14.15,84.48,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,16.26,,,fee schedule,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,16.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",79.2,,,percent of total billed charges,,,16.26,,,fee schedule,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,23.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.95,,,fee schedule,,,14.44,,,fee schedule,,,14.44,,,fee schedule,,,14.15,,,fee schedule,,,16.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,16.26,,,fee schedule,,,16.26,,,fee schedule,,,19.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB METANEPHRINES,3074416,CDM,301,RC,83835,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB METANEPHRINES,3074416,CDM,301,RC,83835,CPT,,,,,,outpatient,facility,,,66,27.72,6.99,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,16.94,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,17.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,16.94,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,24.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.87,,,fee schedule,,,15.04,,,fee schedule,,,15.04,,,fee schedule,,,14.74,,,fee schedule,,,16.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,16.94,,,fee schedule,,,16.94,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MICROALBUMIN URINE QN,3074515,CDM,301,RC,82043,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MICROALBUMIN URINE QN,3074515,CDM,301,RC,82043,CPT,,,,,,outpatient,facility,,,56,23.52,5.03,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.78,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.78,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,8.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.8,,,fee schedule,,,5.13,,,fee schedule,,,5.13,,,fee schedule,,,5.03,,,fee schedule,,,5.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.78,,,fee schedule,,,5.78,,,fee schedule,,,7.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT MYELIN BASIC CSF,3074770,CDM,301,RC,83873,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT MYELIN BASIC CSF,3074770,CDM,301,RC,83873,CPT,,,,,,outpatient,facility,,,63,26.46,14.96,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,17.2,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,17.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,17.2,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,24.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.22,,,fee schedule,,,15.27,,,fee schedule,,,15.27,,,fee schedule,,,14.96,,,fee schedule,,,17.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,17.2,,,fee schedule,,,17.2,,,fee schedule,,,21.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MYOGLOBIN,3074788,CDM,301,RC,83874,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MYOGLOBIN,3074788,CDM,301,RC,83874,CPT,,,,,,outpatient,facility,,,59,24.78,11.24,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,12.92,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,13.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,12.92,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,18.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.44,,,fee schedule,,,11.47,,,fee schedule,,,11.47,,,fee schedule,,,11.24,,,fee schedule,,,12.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,12.92,,,fee schedule,,,12.92,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MYOGLOBIN URINE,3074796,CDM,301,RC,83874,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MYOGLOBIN URINE,3074796,CDM,301,RC,83874,CPT,,,,,,outpatient,facility,,,59,24.78,11.24,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,12.92,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,13.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,12.92,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,18.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.44,,,fee schedule,,,11.47,,,fee schedule,,,11.47,,,fee schedule,,,11.24,,,fee schedule,,,12.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,12.92,,,fee schedule,,,12.92,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NEPHELOMETRY ANALYTE EA,3074820,CDM,301,RC,83883,CPT,,,,,,inpatient,facility,,,41,17.22,34.85,39.36,,34.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,36.9,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NEPHELOMETRY ANALYTE EA,3074820,CDM,301,RC,83883,CPT,,,,,,outpatient,facility,,,41,17.22,11.07,39.36,,34.85,,,percent of total billed charges,,,11.07,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,34.64,,,percent of total billed charges,,,13.6,,,fee schedule,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,34.85,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,13.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.9,,,percent of total billed charges,,,13.6,,,fee schedule,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,19.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.36,,,fee schedule,,,12.08,,,fee schedule,,,12.08,,,fee schedule,,,11.84,,,fee schedule,,,13.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.02,,,percent of total billed charges,,,37.31,,,percent of total billed charges,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NUCLEOTIDASE 5,3074861,CDM,301,RC,83915,CPT,,,,,,inpatient,facility,,,99,41.58,84.15,95.04,,84.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.13,,,percent of total billed charges,,,,,,,,,89.1,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.07,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NUCLEOTIDASE 5,3074861,CDM,301,RC,83915,CPT,,,,,,outpatient,facility,,,99,41.58,9.7,95.04,,84.15,,,percent of total billed charges,,,26.73,,,percent of total billed charges,,,68.11,,,percent of total billed charges,,,66.63,,,percent of total billed charges,,,83.66,,,percent of total billed charges,,,11.15,,,fee schedule,,,86.13,,,percent of total billed charges,,,86.13,,,percent of total billed charges,,,84.15,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,11.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",89.1,,,percent of total billed charges,,,11.15,,,fee schedule,,,92.07,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,16.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.05,,,fee schedule,,,9.9,,,fee schedule,,,9.9,,,fee schedule,,,9.7,,,fee schedule,,,11.15,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",77.32,,,percent of total billed charges,,,90.09,,,percent of total billed charges,,,11.15,,,fee schedule,,,11.15,,,fee schedule,,,13.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD OCCULT FECES SINGLE QL,3074887,CDM,301,RC,82270,CPT,,,,,,inpatient,facility,,,14,5.88,11.9,13.44,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD OCCULT FECES SINGLE QL,3074887,CDM,301,RC,82270,CPT,,,,,,outpatient,facility,,,14,5.88,3.78,13.44,,11.9,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.38,,,fee schedule,,,12.18,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,11.9,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,4.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.6,,,percent of total billed charges,,,4.38,,,fee schedule,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,6.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.91,,,fee schedule,,,3.89,,,fee schedule,,,3.89,,,fee schedule,,,3.81,,,fee schedule,,,4.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.93,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,4.38,,,fee schedule,,,4.38,,,fee schedule,,,3.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD OCCULT OTHER SOURCE QL,3074903,CDM,301,RC,82271,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD OCCULT OTHER SOURCE QL,3074903,CDM,301,RC,82271,CPT,,,,,,outpatient,facility,,,16,6.72,3.99,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.32,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.32,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.18,,,fee schedule,,,4.72,,,fee schedule,,,4.72,,,fee schedule,,,4.63,,,fee schedule,,,5.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.32,,,fee schedule,,,5.32,,,fee schedule,,,3.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BANDS OLIGOCLONAL CSF,3074937,CDM,301,RC,83916,CPT,,,,,,inpatient,facility,,,83,34.86,70.55,79.68,,70.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.21,,,percent of total billed charges,,,,,,,,,74.7,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BANDS OLIGOCLONAL CSF,3074937,CDM,301,RC,83916,CPT,,,,,,outpatient,facility,,,83,34.86,22.41,79.68,,70.55,,,percent of total billed charges,,,22.41,,,percent of total billed charges,,,57.1,,,percent of total billed charges,,,55.86,,,percent of total billed charges,,,70.13,,,percent of total billed charges,,,27.39,,,fee schedule,,,72.21,,,percent of total billed charges,,,72.21,,,percent of total billed charges,,,70.55,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,27.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.7,,,percent of total billed charges,,,27.39,,,fee schedule,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,39.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.98,,,fee schedule,,,24.32,,,fee schedule,,,24.32,,,fee schedule,,,23.83,,,fee schedule,,,27.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.82,,,percent of total billed charges,,,75.53,,,percent of total billed charges,,,27.39,,,fee schedule,,,27.39,,,fee schedule,,,24.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID ORGANIC SINGLE QN,3074952,CDM,301,RC,83921,CPT,,,,,,inpatient,facility,,,195,81.9,165.75,187.2,,165.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,169.65,,,percent of total billed charges,,,,,,,,,175.5,,,percent of total billed charges,,,187.2,,,percent of total billed charges,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,181.35,,,percent of total billed charges,,,185.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID ORGANIC SINGLE QN,3074952,CDM,301,RC,83921,CPT,,,,,,outpatient,facility,,,195,81.9,18.45,187.2,,165.75,,,percent of total billed charges,,,52.65,,,percent of total billed charges,,,134.16,,,percent of total billed charges,,,131.23,,,percent of total billed charges,,,164.78,,,percent of total billed charges,,,21.21,,,fee schedule,,,169.65,,,percent of total billed charges,,,169.65,,,percent of total billed charges,,,165.75,,,percent of total billed charges,,,187.2,,,percent of total billed charges,,,185.25,,,percent of total billed charges,,,21.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.5,,,percent of total billed charges,,,21.21,,,fee schedule,,,181.35,,,percent of total billed charges,,,185.25,,,percent of total billed charges,,,30.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.63,,,fee schedule,,,18.83,,,fee schedule,,,18.83,,,fee schedule,,,18.45,,,fee schedule,,,21.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",152.29,,,percent of total billed charges,,,177.45,,,percent of total billed charges,,,21.21,,,fee schedule,,,21.21,,,fee schedule,,,20.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID ORGANIC SINGLE METHY QN NS,3074960,CDM,301,RC,83921,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID ORGANIC SINGLE METHY QN NS,3074960,CDM,301,RC,83921,CPT,,,,,,outpatient,facility,,,64,26.88,17.28,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,21.21,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,21.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,21.21,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,30.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.63,,,fee schedule,,,18.83,,,fee schedule,,,18.83,,,fee schedule,,,18.45,,,fee schedule,,,21.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,21.21,,,fee schedule,,,21.21,,,fee schedule,,,20.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS ORGANIC EA QL,3074978,CDM,301,RC,83919,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS ORGANIC EA QL,3074978,CDM,301,RC,83919,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.45,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.45,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.21,,,fee schedule,,,14.61,,,fee schedule,,,14.61,,,fee schedule,,,14.32,,,fee schedule,,,16.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.45,,,fee schedule,,,16.45,,,fee schedule,,,20.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS ORGANIC URINE EA QL,3074986,CDM,301,RC,83919,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS ORGANIC URINE EA QL,3074986,CDM,301,RC,83919,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.45,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.45,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.21,,,fee schedule,,,14.61,,,fee schedule,,,14.61,,,fee schedule,,,14.32,,,fee schedule,,,16.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.45,,,fee schedule,,,16.45,,,fee schedule,,,20.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS ORGANIC TOTAL URINE EA QN,3075009,CDM,301,RC,83918,CPT,,,,,,inpatient,facility,,,101,42.42,85.85,96.96,,85.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.87,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS ORGANIC TOTAL URINE EA QN,3075009,CDM,301,RC,83918,CPT,,,,,,outpatient,facility,,,101,42.42,20.18,96.96,,85.85,,,percent of total billed charges,,,27.27,,,percent of total billed charges,,,69.49,,,percent of total billed charges,,,67.97,,,percent of total billed charges,,,85.34,,,percent of total billed charges,,,23.6,,,fee schedule,,,87.87,,,percent of total billed charges,,,87.87,,,percent of total billed charges,,,85.85,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,24.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90.9,,,percent of total billed charges,,,23.6,,,fee schedule,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,34.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.86,,,fee schedule,,,20.96,,,fee schedule,,,20.96,,,fee schedule,,,20.54,,,fee schedule,,,23.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.88,,,percent of total billed charges,,,91.91,,,percent of total billed charges,,,23.6,,,fee schedule,,,23.6,,,fee schedule,,,20.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OSMOLALITY BLOOD,3075017,CDM,301,RC,83930,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OSMOLALITY BLOOD,3075017,CDM,301,RC,83930,CPT,,,,,,outpatient,facility,,,56,23.52,5.75,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.61,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,6.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,6.61,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,9.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.92,,,fee schedule,,,5.87,,,fee schedule,,,5.87,,,fee schedule,,,5.75,,,fee schedule,,,6.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,6.61,,,fee schedule,,,6.61,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OSMOLALITY STOOL,3075033,CDM,301,RC,84999,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OSMOLALITY STOOL,3075033,CDM,301,RC,84999,CPT,,,,,,outpatient,facility,,,68,28.56,18.36,68,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,,,,,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,68,,,fee schedule,,,68,,,fee schedule,,,66.64,,,fee schedule,,,,,,,,,53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,,,,,,,,,,,,,29.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OSMOLALITY URINE,3075041,CDM,301,RC,83935,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OSMOLALITY URINE,3075041,CDM,301,RC,83935,CPT,,,,,,outpatient,facility,,,56,23.52,5.94,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.82,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,6.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,6.82,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,9.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.21,,,fee schedule,,,6.06,,,fee schedule,,,6.06,,,fee schedule,,,5.94,,,fee schedule,,,6.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,6.82,,,fee schedule,,,6.82,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OSTEOCALCIN,3075058,CDM,301,RC,83937,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OSTEOCALCIN,3075058,CDM,301,RC,83937,CPT,,,,,,outpatient,facility,,,90,37.8,24.3,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,29.85,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,30.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,29.85,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,43.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",40.3,,,fee schedule,,,26.51,,,fee schedule,,,26.51,,,fee schedule,,,25.98,,,fee schedule,,,29.85,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,29.85,,,fee schedule,,,29.85,,,fee schedule,,,36.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OXALATE,3075066,CDM,301,RC,83945,CPT,,,,,,inpatient,facility,,,109,45.78,92.65,104.64,,92.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.83,,,percent of total billed charges,,,,,,,,,98.1,,,percent of total billed charges,,,104.64,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.37,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OXALATE,3075066,CDM,301,RC,83945,CPT,,,,,,outpatient,facility,,,109,45.78,12.57,104.64,,92.65,,,percent of total billed charges,,,29.43,,,percent of total billed charges,,,74.99,,,percent of total billed charges,,,73.36,,,percent of total billed charges,,,92.11,,,percent of total billed charges,,,14.45,,,fee schedule,,,94.83,,,percent of total billed charges,,,94.83,,,percent of total billed charges,,,92.65,,,percent of total billed charges,,,104.64,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,14.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",98.1,,,percent of total billed charges,,,14.45,,,fee schedule,,,101.37,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,20.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.51,,,fee schedule,,,12.83,,,fee schedule,,,12.83,,,fee schedule,,,12.57,,,fee schedule,,,14.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",85.13,,,percent of total billed charges,,,99.19,,,percent of total billed charges,,,14.45,,,fee schedule,,,14.45,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OXALATE URINE,3075074,CDM,301,RC,83945,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OXALATE URINE,3075074,CDM,301,RC,83945,CPT,,,,,,outpatient,facility,,,67,28.14,12.57,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,14.45,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,14.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,14.45,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,20.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.51,,,fee schedule,,,12.83,,,fee schedule,,,12.83,,,fee schedule,,,12.57,,,fee schedule,,,14.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,14.45,,,fee schedule,,,14.45,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PH FLUID BODY NOS,3075132,CDM,301,RC,83986,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PH FLUID BODY NOS,3075132,CDM,301,RC,83986,CPT,,,,,,outpatient,facility,,,51,21.42,1.43,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,3.58,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,3.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,3.58,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,5.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.83,,,fee schedule,,,3.18,,,fee schedule,,,3.18,,,fee schedule,,,3.12,,,fee schedule,,,3.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,3.58,,,fee schedule,,,3.58,,,fee schedule,,,1.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENOBARBITAL,3075165,CDM,301,RC,80184,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENOBARBITAL,3075165,CDM,301,RC,80184,CPT,,,,,,outpatient,facility,,,54,22.68,13.32,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,15.3,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,15.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,15.3,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,22.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.66,,,fee schedule,,,13.59,,,fee schedule,,,13.59,,,fee schedule,,,13.32,,,fee schedule,,,15.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,15.3,,,fee schedule,,,15.3,,,fee schedule,,,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENYLALANINE BLOOD,3075181,CDM,301,RC,84030,CPT,,,,,,inpatient,facility,,,17,7.14,14.45,16.32,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.79,,,percent of total billed charges,,,,,,,,,15.3,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENYLALANINE BLOOD,3075181,CDM,301,RC,84030,CPT,,,,,,outpatient,facility,,,17,7.14,4.59,16.32,,14.45,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,5.5,,,fee schedule,,,14.79,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,5.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.3,,,percent of total billed charges,,,5.5,,,fee schedule,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,7.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.43,,,fee schedule,,,4.88,,,fee schedule,,,4.88,,,fee schedule,,,4.78,,,fee schedule,,,5.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",13.28,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,5.5,,,fee schedule,,,5.5,,,fee schedule,,,6.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENYTOIN FREE,3075215,CDM,301,RC,80186,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENYTOIN FREE,3075215,CDM,301,RC,80186,CPT,,,,,,outpatient,facility,,,63,26.46,11.98,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,13.76,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,14.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,13.76,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,19.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.58,,,fee schedule,,,12.22,,,fee schedule,,,12.22,,,fee schedule,,,11.98,,,fee schedule,,,13.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,13.76,,,fee schedule,,,13.76,,,fee schedule,,,16.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENYTOIN TOTAL,3075223,CDM,301,RC,80185,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENYTOIN TOTAL,3075223,CDM,301,RC,80185,CPT,,,,,,outpatient,facility,,,54,22.68,11.53,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,13.25,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,13.25,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,16.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID PHOSPHATASE PROSTATIC,3075249,CDM,301,RC,84066,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID PHOSPHATASE PROSTATIC,3075249,CDM,301,RC,84066,CPT,,,,,,outpatient,facility,,,60,25.2,8.41,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,9.66,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,9.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,9.66,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,14.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.04,,,fee schedule,,,8.58,,,fee schedule,,,8.58,,,fee schedule,,,8.41,,,fee schedule,,,9.66,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,9.66,,,fee schedule,,,9.66,,,fee schedule,,,10.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALKALINE PHOSPHATASE ISOENZYMES,3075264,CDM,301,RC,84080,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALKALINE PHOSPHATASE ISOENZYMES,3075264,CDM,301,RC,84080,CPT,,,,,,outpatient,facility,,,57,23.94,12.86,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,14.78,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,15.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,14.78,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,21.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.95,,,fee schedule,,,13.12,,,fee schedule,,,13.12,,,fee schedule,,,12.86,,,fee schedule,,,14.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,14.78,,,fee schedule,,,14.78,,,fee schedule,,,18.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALKALINE PHOSPHATASE,3075272,CDM,301,RC,84075,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALKALINE PHOSPHATASE,3075272,CDM,301,RC,84075,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.18,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.18,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHOSPHORUS INORGANIC,3075298,CDM,301,RC,84100,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHOSPHORUS INORGANIC,3075298,CDM,301,RC,84100,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.74,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.74,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.4,,,fee schedule,,,4.21,,,fee schedule,,,4.21,,,fee schedule,,,4.13,,,fee schedule,,,4.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.74,,,fee schedule,,,4.74,,,fee schedule,,,5.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHOSPHORUS INORGANIC URINE,3075306,CDM,301,RC,84105,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHOSPHORUS INORGANIC URINE,3075306,CDM,301,RC,84105,CPT,,,,,,outpatient,facility,,,52,21.84,5.03,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,5.78,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,5.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,5.78,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,8.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.8,,,fee schedule,,,5.13,,,fee schedule,,,5.13,,,fee schedule,,,5.03,,,fee schedule,,,5.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.78,,,fee schedule,,,5.78,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PORPHOBILINOGEN URINE QN,3075322,CDM,301,RC,84110,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PORPHOBILINOGEN URINE QN,3075322,CDM,301,RC,84110,CPT,,,,,,outpatient,facility,,,62,26.04,4.17,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,8.44,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,8.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,8.44,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.39,,,fee schedule,,,7.49,,,fee schedule,,,7.49,,,fee schedule,,,7.34,,,fee schedule,,,8.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,8.44,,,fee schedule,,,8.44,,,fee schedule,,,4.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PORPHYRINS URINE QN ANDFRCTN,3075330,CDM,301,RC,84120,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PORPHYRINS URINE QN ANDFRCTN,3075330,CDM,301,RC,84120,CPT,,,,,,outpatient,facility,,,62,26.04,11.29,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,14.71,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,14.71,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,21.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.86,,,fee schedule,,,13.06,,,fee schedule,,,13.06,,,fee schedule,,,12.8,,,fee schedule,,,14.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,14.71,,,fee schedule,,,14.71,,,fee schedule,,,11.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB POTASS SRM PLASMA BLD WHL,3075355,CDM,301,RC,84132,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB POTASS SRM PLASMA BLD WHL,3075355,CDM,301,RC,84132,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.76,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.76,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.43,,,fee schedule,,,4.23,,,fee schedule,,,4.23,,,fee schedule,,,4.15,,,fee schedule,,,4.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.76,,,fee schedule,,,4.76,,,fee schedule,,,5.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB POTASS FLUID BODY,3075363,CDM,301,RC,84999,CPT,,,,,,inpatient,facility,,,425,178.5,361.25,408,,361.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,369.75,,,percent of total billed charges,,,,,,,,,382.5,,,percent of total billed charges,,,408,,,percent of total billed charges,,,403.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,395.25,,,percent of total billed charges,,,403.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB POTASS FLUID BODY,3075363,CDM,301,RC,84999,CPT,,,,,,outpatient,facility,,,425,178.5,29.25,425,,361.25,,,percent of total billed charges,,,114.75,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,286.02,,,percent of total billed charges,,,359.13,,,percent of total billed charges,,,,,,,,,369.75,,,percent of total billed charges,,,369.75,,,percent of total billed charges,,,361.25,,,percent of total billed charges,,,408,,,percent of total billed charges,,,403.75,,,percent of total billed charges,,,,,,,,,382.5,,,percent of total billed charges,,,,,,,,,395.25,,,percent of total billed charges,,,403.75,,,percent of total billed charges,,,,,,,,,,,,,,,425,,,fee schedule,,,425,,,fee schedule,,,416.5,,,fee schedule,,,,,,,,,331.93,,,percent of total billed charges,,,386.75,,,percent of total billed charges,,,,,,,,,,,,,,,29.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB POTASS URINE,3075389,CDM,301,RC,84133,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB POTASS URINE,3075389,CDM,301,RC,84133,CPT,,,,,,outpatient,facility,,,55,23.1,4.12,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,4.73,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,4.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,4.73,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,6.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.39,,,fee schedule,,,4.2,,,fee schedule,,,4.2,,,fee schedule,,,4.12,,,fee schedule,,,4.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,4.73,,,fee schedule,,,4.73,,,fee schedule,,,5.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PREALBUMIN,3075397,CDM,301,RC,84134,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PREALBUMIN,3075397,CDM,301,RC,84134,CPT,,,,,,outpatient,facility,,,54,22.68,6.95,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,14.59,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,14.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,14.59,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,21.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.7,,,fee schedule,,,12.96,,,fee schedule,,,12.96,,,fee schedule,,,12.7,,,fee schedule,,,14.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,14.59,,,fee schedule,,,14.59,,,fee schedule,,,6.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PREGNENOLONE,3075421,CDM,301,RC,84140,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PREGNENOLONE,3075421,CDM,301,RC,84140,CPT,,,,,,outpatient,facility,,,63,26.46,9.92,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,20.67,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,20.67,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,29.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.9,,,fee schedule,,,18.35,,,fee schedule,,,18.35,,,fee schedule,,,17.98,,,fee schedule,,,20.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,20.67,,,fee schedule,,,20.67,,,fee schedule,,,9.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB 17 HYDROXYPREGNENOLONE,3075439,CDM,301,RC,84143,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB 17 HYDROXYPREGNENOLONE,3075439,CDM,301,RC,84143,CPT,,,,,,outpatient,facility,,,69,28.98,9.92,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,22.81,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,23.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,22.81,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,33.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.79,,,fee schedule,,,20.26,,,fee schedule,,,20.26,,,fee schedule,,,19.85,,,fee schedule,,,22.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,22.81,,,fee schedule,,,22.81,,,fee schedule,,,9.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PEPTIDE NATRIURETIC PB,3075454,CDM,301,RC,83880,CPT,,,,,,inpatient,facility,,,118,49.56,100.3,113.28,,100.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.66,,,percent of total billed charges,,,,,,,,,106.2,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PEPTIDE NATRIURETIC PB,3075454,CDM,301,RC,83880,CPT,,,,,,outpatient,facility,,,118,49.56,31.86,113.28,,100.3,,,percent of total billed charges,,,31.86,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,79.41,,,percent of total billed charges,,,99.71,,,percent of total billed charges,,,39.26,,,fee schedule,,,102.66,,,percent of total billed charges,,,102.66,,,percent of total billed charges,,,100.3,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,40.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",106.2,,,percent of total billed charges,,,39.26,,,fee schedule,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,56.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53,,,fee schedule,,,34.86,,,fee schedule,,,34.86,,,fee schedule,,,34.16,,,fee schedule,,,39.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",92.16,,,percent of total billed charges,,,107.38,,,percent of total billed charges,,,39.26,,,fee schedule,,,39.26,,,fee schedule,,,41.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROCAINAMIDE W NAPA,3075462,CDM,301,RC,80192,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROCAINAMIDE W NAPA,3075462,CDM,301,RC,80192,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.75,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.75,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.61,,,fee schedule,,,14.87,,,fee schedule,,,14.87,,,fee schedule,,,14.57,,,fee schedule,,,16.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.75,,,fee schedule,,,16.75,,,fee schedule,,,20.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROGESTERONE,3075470,CDM,301,RC,84144,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROGESTERONE,3075470,CDM,301,RC,84144,CPT,,,,,,outpatient,facility,,,63,26.46,17.01,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,20.86,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,20.86,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,30.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.16,,,fee schedule,,,18.52,,,fee schedule,,,18.52,,,fee schedule,,,18.15,,,fee schedule,,,20.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,20.86,,,fee schedule,,,20.86,,,fee schedule,,,25.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROINSULIN,3075488,CDM,301,RC,84206,CPT,,,,,,inpatient,facility,,,81,34.02,68.85,77.76,,68.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.47,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROINSULIN,3075488,CDM,301,RC,84206,CPT,,,,,,outpatient,facility,,,81,34.02,21.84,77.76,,68.85,,,percent of total billed charges,,,21.87,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,54.51,,,percent of total billed charges,,,68.44,,,percent of total billed charges,,,26.69,,,fee schedule,,,70.47,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,27.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72.9,,,percent of total billed charges,,,26.69,,,fee schedule,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,38.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.03,,,fee schedule,,,23.7,,,fee schedule,,,23.7,,,fee schedule,,,23.23,,,fee schedule,,,26.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",63.26,,,percent of total billed charges,,,73.71,,,percent of total billed charges,,,26.69,,,fee schedule,,,26.69,,,fee schedule,,,21.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROLACTIN,3075496,CDM,301,RC,84146,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROLACTIN,3075496,CDM,301,RC,84146,CPT,,,,,,outpatient,facility,,,59,24.78,15.93,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,19.38,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,19.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,19.38,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,28.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.16,,,fee schedule,,,17.21,,,fee schedule,,,17.21,,,fee schedule,,,16.87,,,fee schedule,,,19.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,19.38,,,fee schedule,,,19.38,,,fee schedule,,,23.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT FLUID BODY,3075553,CDM,301,RC,84157,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT FLUID BODY,3075553,CDM,301,RC,84157,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,11.52,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,4,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,4,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.4,,,fee schedule,,,3.55,,,fee schedule,,,3.55,,,fee schedule,,,3.48,,,fee schedule,,,4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,4,,,fee schedule,,,4,,,fee schedule,,,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT FLUID CEREBROSPINAL,3075561,CDM,301,RC,84157,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT FLUID CEREBROSPINAL,3075561,CDM,301,RC,84157,CPT,,,,,,outpatient,facility,,,56,23.52,3.37,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,4,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,4.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,4,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.4,,,fee schedule,,,3.55,,,fee schedule,,,3.55,,,fee schedule,,,3.48,,,fee schedule,,,4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,4,,,fee schedule,,,4,,,fee schedule,,,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT TTL SRM PLASMA BLD WHL,3075579,CDM,301,RC,84155,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT TTL SRM PLASMA BLD WHL,3075579,CDM,301,RC,84155,CPT,,,,,,outpatient,facility,,,56,23.52,3.19,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,3.67,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,3.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,3.67,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.95,,,fee schedule,,,3.26,,,fee schedule,,,3.26,,,fee schedule,,,3.19,,,fee schedule,,,3.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,3.67,,,fee schedule,,,3.67,,,fee schedule,,,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT URINE,3075587,CDM,301,RC,84156,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT URINE,3075587,CDM,301,RC,84156,CPT,,,,,,outpatient,facility,,,56,23.52,3.19,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,3.67,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,3.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,3.67,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.95,,,fee schedule,,,3.26,,,fee schedule,,,3.26,,,fee schedule,,,3.19,,,fee schedule,,,3.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,3.67,,,fee schedule,,,3.67,,,fee schedule,,,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT URINE TIMED,3075595,CDM,301,RC,84156,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT URINE TIMED,3075595,CDM,301,RC,84156,CPT,,,,,,outpatient,facility,,,12,5.04,3.19,11.52,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.67,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,3.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.67,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.95,,,fee schedule,,,3.26,,,fee schedule,,,3.26,,,fee schedule,,,3.19,,,fee schedule,,,3.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.67,,,fee schedule,,,3.67,,,fee schedule,,,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROTOPORPHYRIN RBC QN,3075603,CDM,301,RC,84202,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROTOPORPHYRIN RBC QN,3075603,CDM,301,RC,84202,CPT,,,,,,outpatient,facility,,,111,46.62,12.49,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,14.35,,,fee schedule,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,14.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",99.9,,,percent of total billed charges,,,14.35,,,fee schedule,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,20.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.37,,,fee schedule,,,12.74,,,fee schedule,,,12.74,,,fee schedule,,,12.49,,,fee schedule,,,14.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,14.35,,,fee schedule,,,14.35,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PSA FREE,3075645,CDM,301,RC,84154,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PSA FREE,3075645,CDM,301,RC,84154,CPT,,,,,,outpatient,facility,,,56,23.52,15.12,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,18.39,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,18.39,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,26.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.83,,,fee schedule,,,16.33,,,fee schedule,,,16.33,,,fee schedule,,,16,,,fee schedule,,,18.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,18.39,,,fee schedule,,,18.39,,,fee schedule,,,22.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PSA TOTAL,3075652,CDM,301,RC,84153,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PSA TOTAL,3075652,CDM,301,RC,84153,CPT,,,,,,outpatient,facility,,,56,23.52,15.12,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,18.39,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,18.39,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,26.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.83,,,fee schedule,,,16.33,,,fee schedule,,,16.33,,,fee schedule,,,16,,,fee schedule,,,18.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,18.39,,,fee schedule,,,18.39,,,fee schedule,,,22.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE,3075660,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE,3075660,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE C TERMINAL,3075678,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE C TERMINAL,3075678,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE INTRAOP POST 10 MN,3075694,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE INTRAOP POST 10 MN,3075694,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE INTRAOP POST 5 MN,3075702,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE INTRAOP POST 5 MN,3075702,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE INTRAOP BASELINE 1,3075710,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE INTRAOP BASELINE 1,3075710,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE INTRAOP BASELINE 2,3075728,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE INTRAOP BASELINE 2,3075728,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE INTRAOP EA ADDL,3075736,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE INTRAOP EA ADDL,3075736,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PYRUVATE,3075751,CDM,301,RC,84210,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PYRUVATE,3075751,CDM,301,RC,84210,CPT,,,,,,outpatient,facility,,,44,18.48,6.99,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.48,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.48,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.55,,,fee schedule,,,12.86,,,fee schedule,,,12.86,,,fee schedule,,,12.6,,,fee schedule,,,14.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.48,,,fee schedule,,,14.48,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB QUININE,3075777,CDM,301,RC,84228,CPT,,,,,,inpatient,facility,,,136,57.12,115.6,130.56,,115.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.32,,,percent of total billed charges,,,,,,,,,122.4,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB QUININE,3075777,CDM,301,RC,84228,CPT,,,,,,outpatient,facility,,,136,57.12,10.12,130.56,,115.6,,,percent of total billed charges,,,36.72,,,percent of total billed charges,,,93.57,,,percent of total billed charges,,,91.53,,,percent of total billed charges,,,114.92,,,percent of total billed charges,,,11.63,,,fee schedule,,,118.32,,,percent of total billed charges,,,118.32,,,percent of total billed charges,,,115.6,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,11.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",122.4,,,percent of total billed charges,,,11.63,,,fee schedule,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,16.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.7,,,fee schedule,,,10.33,,,fee schedule,,,10.33,,,fee schedule,,,10.12,,,fee schedule,,,11.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",106.22,,,percent of total billed charges,,,123.76,,,percent of total billed charges,,,11.63,,,fee schedule,,,11.63,,,fee schedule,,,14.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB RECEPTOR ACETYLCHOLINE NON ENDO,3075819,CDM,301,RC,84238,CPT,,,,,,inpatient,facility,,,110,46.2,93.5,105.6,,93.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,95.7,,,percent of total billed charges,,,,,,,,,99,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,102.3,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RECEPTOR ACETYLCHOLINE NON ENDO,3075819,CDM,301,RC,84238,CPT,,,,,,outpatient,facility,,,110,46.2,29.7,105.6,,93.5,,,percent of total billed charges,,,29.7,,,percent of total billed charges,,,75.68,,,percent of total billed charges,,,74.03,,,percent of total billed charges,,,92.95,,,percent of total billed charges,,,36.57,,,fee schedule,,,95.7,,,percent of total billed charges,,,95.7,,,percent of total billed charges,,,93.5,,,percent of total billed charges,,,105.6,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,37.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",99,,,percent of total billed charges,,,36.57,,,fee schedule,,,102.3,,,percent of total billed charges,,,104.5,,,percent of total billed charges,,,53.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.37,,,fee schedule,,,32.47,,,fee schedule,,,32.47,,,fee schedule,,,31.82,,,fee schedule,,,36.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",85.91,,,percent of total billed charges,,,100.1,,,percent of total billed charges,,,36.57,,,fee schedule,,,36.57,,,fee schedule,,,44.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL FUNCTION RENAL,3075843,CDM,301,RC,80069,CPT,,,,,,inpatient,facility,,,27,11.34,22.95,25.92,,22.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,percent of total billed charges,,,,,,,,,24.3,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.11,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL FUNCTION RENAL,3075843,CDM,301,RC,80069,CPT,,,,,,outpatient,facility,,,27,11.34,7.29,25.92,,22.95,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,18.58,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,22.81,,,percent of total billed charges,,,8.68,,,fee schedule,,,23.49,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,8.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.3,,,percent of total billed charges,,,8.68,,,fee schedule,,,25.11,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,12.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.72,,,fee schedule,,,7.71,,,fee schedule,,,7.71,,,fee schedule,,,7.56,,,fee schedule,,,8.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",21.09,,,percent of total billed charges,,,24.57,,,percent of total billed charges,,,8.68,,,fee schedule,,,8.68,,,fee schedule,,,10.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SELENIUM,3075884,CDM,301,RC,84255,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SELENIUM,3075884,CDM,301,RC,84255,CPT,,,,,,outpatient,facility,,,77,32.34,20.79,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,25.53,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,26.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,25.53,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,37.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.47,,,fee schedule,,,22.67,,,fee schedule,,,22.67,,,fee schedule,,,22.22,,,fee schedule,,,25.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,25.53,,,fee schedule,,,25.53,,,fee schedule,,,31.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SEROTONIN,3075892,CDM,301,RC,84260,CPT,,,,,,inpatient,facility,,,93,39.06,79.05,89.28,,79.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.91,,,percent of total billed charges,,,,,,,,,83.7,,,percent of total billed charges,,,89.28,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.49,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SEROTONIN,3075892,CDM,301,RC,84260,CPT,,,,,,outpatient,facility,,,93,39.06,25.11,89.28,,79.05,,,percent of total billed charges,,,25.11,,,percent of total billed charges,,,63.98,,,percent of total billed charges,,,62.59,,,percent of total billed charges,,,78.58,,,percent of total billed charges,,,30.98,,,fee schedule,,,80.91,,,percent of total billed charges,,,80.91,,,percent of total billed charges,,,79.05,,,percent of total billed charges,,,89.28,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,31.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.7,,,percent of total billed charges,,,30.98,,,fee schedule,,,86.49,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,44.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.82,,,fee schedule,,,27.51,,,fee schedule,,,27.51,,,fee schedule,,,26.96,,,fee schedule,,,30.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",72.63,,,percent of total billed charges,,,84.63,,,percent of total billed charges,,,30.98,,,fee schedule,,,30.98,,,fee schedule,,,37.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HORMONE SEX BINDING GLOBULIN,3075900,CDM,301,RC,84270,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HORMONE SEX BINDING GLOBULIN,3075900,CDM,301,RC,84270,CPT,,,,,,outpatient,facility,,,66,27.72,17.82,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,21.73,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,22.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,21.73,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,31.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.34,,,fee schedule,,,19.3,,,fee schedule,,,19.3,,,fee schedule,,,18.91,,,fee schedule,,,21.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,21.73,,,fee schedule,,,21.73,,,fee schedule,,,21.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SODIUM SRM PLASMA BLD WHL,3075934,CDM,301,RC,84295,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SODIUM SRM PLASMA BLD WHL,3075934,CDM,301,RC,84295,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.81,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.81,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.49,,,fee schedule,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,4.18,,,fee schedule,,,4.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.81,,,fee schedule,,,4.81,,,fee schedule,,,5.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SODIUM FLUID BODY,3075942,CDM,301,RC,84302,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SODIUM FLUID BODY,3075942,CDM,301,RC,84302,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.86,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.86,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,7.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.56,,,fee schedule,,,4.32,,,fee schedule,,,4.32,,,fee schedule,,,4.23,,,fee schedule,,,4.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.86,,,fee schedule,,,4.86,,,fee schedule,,,5.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SODIUM URINE,3075975,CDM,301,RC,84300,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SODIUM URINE,3075975,CDM,301,RC,84300,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.06,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.06,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.83,,,fee schedule,,,4.49,,,fee schedule,,,4.49,,,fee schedule,,,4.4,,,fee schedule,,,5.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.06,,,fee schedule,,,5.06,,,fee schedule,,,5.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SODIUM URINE TIMED,3075983,CDM,301,RC,84300,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SODIUM URINE TIMED,3075983,CDM,301,RC,84300,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.06,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.06,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.83,,,fee schedule,,,4.49,,,fee schedule,,,4.49,,,fee schedule,,,4.4,,,fee schedule,,,5.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.06,,,fee schedule,,,5.06,,,fee schedule,,,5.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SODIUM OTHER SOURCE,3075991,CDM,301,RC,84302,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SODIUM OTHER SOURCE,3075991,CDM,301,RC,84302,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.86,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.86,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,7.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.56,,,fee schedule,,,4.32,,,fee schedule,,,4.32,,,fee schedule,,,4.23,,,fee schedule,,,4.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.86,,,fee schedule,,,4.86,,,fee schedule,,,5.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SOMATOSTATIN,3076015,CDM,301,RC,84307,CPT,,,,,,inpatient,facility,,,82,34.44,69.7,78.72,,69.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.34,,,percent of total billed charges,,,,,,,,,73.8,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SOMATOSTATIN,3076015,CDM,301,RC,84307,CPT,,,,,,outpatient,facility,,,82,34.44,15.91,78.72,,69.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,55.19,,,percent of total billed charges,,,69.29,,,percent of total billed charges,,,18.28,,,fee schedule,,,71.34,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,69.7,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,18.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",73.8,,,percent of total billed charges,,,18.28,,,fee schedule,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,26.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.68,,,fee schedule,,,16.23,,,fee schedule,,,16.23,,,fee schedule,,,15.91,,,fee schedule,,,18.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.04,,,percent of total billed charges,,,74.62,,,percent of total billed charges,,,18.28,,,fee schedule,,,18.28,,,fee schedule,,,22.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GRAVITY SPECIFIC FLUID BODY,3076031,CDM,301,RC,84315,CPT,,,,,,inpatient,facility,,,10,4.2,8.5,9.6,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,,percent of total billed charges,,,,,,,,,9,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GRAVITY SPECIFIC FLUID BODY,3076031,CDM,301,RC,84315,CPT,,,,,,outpatient,facility,,,10,4.2,2.7,9.6,,8.5,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,3.28,,,fee schedule,,,8.7,,,percent of total billed charges,,,8.7,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,3.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9,,,percent of total billed charges,,,3.28,,,fee schedule,,,9.3,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,4.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.43,,,fee schedule,,,2.91,,,fee schedule,,,2.91,,,fee schedule,,,2.85,,,fee schedule,,,3.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",7.81,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,3.28,,,fee schedule,,,3.28,,,fee schedule,,,3.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SPCTPHOT ANALYTE NS,3076056,CDM,301,RC,84311,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SPCTPHOT ANALYTE NS,3076056,CDM,301,RC,84311,CPT,,,,,,outpatient,facility,,,58,24.36,7.05,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,8.1,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,8.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,8.1,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,11.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.94,,,fee schedule,,,7.19,,,fee schedule,,,7.19,,,fee schedule,,,7.05,,,fee schedule,,,8.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,8.1,,,fee schedule,,,8.1,,,fee schedule,,,8.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUGARS MULTIPLE QL EA,3076072,CDM,301,RC,84377,CPT,,,,,,inpatient,facility,,,229,96.18,194.65,219.84,,194.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,199.23,,,percent of total billed charges,,,,,,,,,206.1,,,percent of total billed charges,,,219.84,,,percent of total billed charges,,,217.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,212.97,,,percent of total billed charges,,,217.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUGARS MULTIPLE QL EA,3076072,CDM,301,RC,84377,CPT,,,,,,outpatient,facility,,,229,96.18,4.78,219.84,,194.65,,,percent of total billed charges,,,61.83,,,percent of total billed charges,,,157.55,,,percent of total billed charges,,,154.12,,,percent of total billed charges,,,193.5,,,percent of total billed charges,,,5.5,,,fee schedule,,,199.23,,,percent of total billed charges,,,199.23,,,percent of total billed charges,,,194.65,,,percent of total billed charges,,,219.84,,,percent of total billed charges,,,217.55,,,percent of total billed charges,,,5.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",206.1,,,percent of total billed charges,,,5.5,,,fee schedule,,,212.97,,,percent of total billed charges,,,217.55,,,percent of total billed charges,,,7.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.43,,,fee schedule,,,4.88,,,fee schedule,,,4.88,,,fee schedule,,,4.78,,,fee schedule,,,5.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",178.85,,,percent of total billed charges,,,208.39,,,percent of total billed charges,,,5.5,,,fee schedule,,,5.5,,,fee schedule,,,6.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SULFATE URINE,3076080,CDM,301,RC,84392,CPT,,,,,,inpatient,facility,,,17,7.14,14.45,16.32,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.79,,,percent of total billed charges,,,,,,,,,15.3,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SULFATE URINE,3076080,CDM,301,RC,84392,CPT,,,,,,outpatient,facility,,,17,7.14,4.59,16.32,,14.45,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,5.49,,,fee schedule,,,14.79,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,5.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.3,,,percent of total billed charges,,,5.49,,,fee schedule,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,7.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.41,,,fee schedule,,,4.88,,,fee schedule,,,4.88,,,fee schedule,,,4.78,,,fee schedule,,,5.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",13.28,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,5.49,,,fee schedule,,,5.49,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOGLOBIN SULFHEMOGLOBIN QN,3076098,CDM,301,RC,83060,CPT,,,,,,inpatient,facility,,,172,72.24,146.2,165.12,,146.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.64,,,percent of total billed charges,,,,,,,,,154.8,,,percent of total billed charges,,,165.12,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,159.96,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOGLOBIN SULFHEMOGLOBIN QN,3076098,CDM,301,RC,83060,CPT,,,,,,outpatient,facility,,,172,72.24,6.99,165.12,,146.2,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,118.34,,,percent of total billed charges,,,115.76,,,percent of total billed charges,,,145.34,,,percent of total billed charges,,,8.8,,,fee schedule,,,149.64,,,percent of total billed charges,,,149.64,,,percent of total billed charges,,,146.2,,,percent of total billed charges,,,165.12,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,8.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",154.8,,,percent of total billed charges,,,8.8,,,fee schedule,,,159.96,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,12.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.88,,,fee schedule,,,7.81,,,fee schedule,,,7.81,,,fee schedule,,,7.65,,,fee schedule,,,8.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",134.33,,,percent of total billed charges,,,156.52,,,percent of total billed charges,,,8.8,,,fee schedule,,,8.8,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UPTAKE HORMONE T3,3076114,CDM,301,RC,84479,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UPTAKE HORMONE T3,3076114,CDM,301,RC,84479,CPT,,,,,,outpatient,facility,,,56,23.52,5.64,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.47,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,6.47,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,5.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TACROLIMUS FK 506,3076122,CDM,301,RC,80197,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TACROLIMUS FK 506,3076122,CDM,301,RC,80197,CPT,,,,,,outpatient,facility,,,57,23.94,11.95,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,13.73,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,13.73,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,19.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.54,,,fee schedule,,,12.19,,,fee schedule,,,12.19,,,fee schedule,,,11.95,,,fee schedule,,,13.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,13.73,,,fee schedule,,,13.73,,,fee schedule,,,16.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TESTOSTERONE TOTAL,3076148,CDM,301,RC,84403,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TESTOSTERONE TOTAL,3076148,CDM,301,RC,84403,CPT,,,,,,outpatient,facility,,,78,32.76,21.06,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,25.81,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,26.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,25.81,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,37.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.84,,,fee schedule,,,22.92,,,fee schedule,,,22.92,,,fee schedule,,,22.46,,,fee schedule,,,25.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,25.81,,,fee schedule,,,25.81,,,fee schedule,,,31.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TESTOSTERONE FREE,3076155,CDM,301,RC,84402,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TESTOSTERONE FREE,3076155,CDM,301,RC,84402,CPT,,,,,,outpatient,facility,,,77,32.34,20.79,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,25.47,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,25.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,25.47,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,36.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.38,,,fee schedule,,,22.62,,,fee schedule,,,22.62,,,fee schedule,,,22.17,,,fee schedule,,,25.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,25.47,,,fee schedule,,,25.47,,,fee schedule,,,31.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THEOPHYLLINE,3076189,CDM,301,RC,80198,CPT,,,,,,inpatient,facility,,,43,18.06,36.55,41.28,,36.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.41,,,percent of total billed charges,,,,,,,,,38.7,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THEOPHYLLINE,3076189,CDM,301,RC,80198,CPT,,,,,,outpatient,facility,,,43,18.06,11.61,41.28,,36.55,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,29.58,,,percent of total billed charges,,,28.94,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,14.14,,,fee schedule,,,37.41,,,percent of total billed charges,,,37.41,,,percent of total billed charges,,,36.55,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,14.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",38.7,,,percent of total billed charges,,,14.14,,,fee schedule,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,20.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.09,,,fee schedule,,,12.56,,,fee schedule,,,12.56,,,fee schedule,,,12.31,,,fee schedule,,,14.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",33.58,,,percent of total billed charges,,,39.13,,,percent of total billed charges,,,14.14,,,fee schedule,,,14.14,,,fee schedule,,,17.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROGLOBULIN,3076221,CDM,301,RC,84432,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROGLOBULIN,3076221,CDM,301,RC,84432,CPT,,,,,,outpatient,facility,,,58,24.36,13.97,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,16.06,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,16.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,16.06,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,23.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.68,,,fee schedule,,,14.26,,,fee schedule,,,14.26,,,fee schedule,,,13.97,,,fee schedule,,,16.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,16.06,,,fee schedule,,,16.06,,,fee schedule,,,19.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROXINE BINDING GLOBULIN,3076239,CDM,301,RC,84442,CPT,,,,,,inpatient,facility,,,45,18.9,38.25,43.2,,38.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,39.15,,,percent of total billed charges,,,,,,,,,40.5,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41.85,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROXINE BINDING GLOBULIN,3076239,CDM,301,RC,84442,CPT,,,,,,outpatient,facility,,,45,18.9,12.15,43.2,,38.25,,,percent of total billed charges,,,12.15,,,percent of total billed charges,,,30.96,,,percent of total billed charges,,,30.28,,,percent of total billed charges,,,38.02,,,percent of total billed charges,,,14.78,,,fee schedule,,,39.15,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,,38.25,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,15.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",40.5,,,percent of total billed charges,,,14.78,,,fee schedule,,,41.85,,,percent of total billed charges,,,42.75,,,percent of total billed charges,,,21.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.95,,,fee schedule,,,13.12,,,fee schedule,,,13.12,,,fee schedule,,,12.86,,,fee schedule,,,14.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",35.14,,,percent of total billed charges,,,40.95,,,percent of total billed charges,,,14.78,,,fee schedule,,,14.78,,,fee schedule,,,18.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROID STIMULATING IMMUN GLOB,3076247,CDM,301,RC,84445,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROID STIMULATING IMMUN GLOB,3076247,CDM,301,RC,84445,CPT,,,,,,outpatient,facility,,,153,64.26,41.31,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,50.86,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,51.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,50.86,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,73.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.66,,,fee schedule,,,45.16,,,fee schedule,,,45.16,,,fee schedule,,,44.26,,,fee schedule,,,50.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,50.86,,,fee schedule,,,50.86,,,fee schedule,,,62.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROXINE T4 FREE,3076254,CDM,301,RC,84439,CPT,,,,,,inpatient,facility,,,28,11.76,23.8,26.88,,23.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.36,,,percent of total billed charges,,,,,,,,,25.2,,,percent of total billed charges,,,26.88,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.04,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROXINE T4 FREE,3076254,CDM,301,RC,84439,CPT,,,,,,outpatient,facility,,,28,11.76,7.56,26.88,,23.8,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,19.26,,,percent of total billed charges,,,18.84,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,9.02,,,fee schedule,,,24.36,,,percent of total billed charges,,,24.36,,,percent of total billed charges,,,23.8,,,percent of total billed charges,,,26.88,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,9.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.2,,,percent of total billed charges,,,9.02,,,fee schedule,,,26.04,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,13.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.18,,,fee schedule,,,8.01,,,fee schedule,,,8.01,,,fee schedule,,,7.85,,,fee schedule,,,9.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",21.87,,,percent of total billed charges,,,25.48,,,percent of total billed charges,,,9.02,,,fee schedule,,,9.02,,,fee schedule,,,11.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROXINE T4 TOTAL,3076262,CDM,301,RC,84436,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROXINE T4 TOTAL,3076262,CDM,301,RC,84436,CPT,,,,,,outpatient,facility,,,56,23.52,5.98,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,6.87,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,7.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,6.87,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,9.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.27,,,fee schedule,,,6.1,,,fee schedule,,,6.1,,,fee schedule,,,5.98,,,fee schedule,,,6.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,6.87,,,fee schedule,,,6.87,,,fee schedule,,,8.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TOBRAMYCIN PEAK,3076288,CDM,301,RC,80200,CPT,,,,,,inpatient,facility,,,49,20.58,41.65,47.04,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.63,,,percent of total billed charges,,,,,,,,,44.1,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TOBRAMYCIN PEAK,3076288,CDM,301,RC,80200,CPT,,,,,,outpatient,facility,,,49,20.58,13.23,47.04,,41.65,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,33.71,,,percent of total billed charges,,,32.98,,,percent of total billed charges,,,41.41,,,percent of total billed charges,,,16.13,,,fee schedule,,,42.63,,,percent of total billed charges,,,42.63,,,percent of total billed charges,,,41.65,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,16.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",44.1,,,percent of total billed charges,,,16.13,,,fee schedule,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,23.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.78,,,fee schedule,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,14.03,,,fee schedule,,,16.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",38.27,,,percent of total billed charges,,,44.59,,,percent of total billed charges,,,16.13,,,fee schedule,,,16.13,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TOBRAMYCIN RANDOM,3076296,CDM,301,RC,80200,CPT,,,,,,inpatient,facility,,,49,20.58,41.65,47.04,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.63,,,percent of total billed charges,,,,,,,,,44.1,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TOBRAMYCIN RANDOM,3076296,CDM,301,RC,80200,CPT,,,,,,outpatient,facility,,,49,20.58,13.23,47.04,,41.65,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,33.71,,,percent of total billed charges,,,32.98,,,percent of total billed charges,,,41.41,,,percent of total billed charges,,,16.13,,,fee schedule,,,42.63,,,percent of total billed charges,,,42.63,,,percent of total billed charges,,,41.65,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,16.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",44.1,,,percent of total billed charges,,,16.13,,,fee schedule,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,23.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.78,,,fee schedule,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,14.03,,,fee schedule,,,16.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",38.27,,,percent of total billed charges,,,44.59,,,percent of total billed charges,,,16.13,,,fee schedule,,,16.13,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TOBRAMYCIN TROUGH,3076304,CDM,301,RC,80200,CPT,,,,,,inpatient,facility,,,49,20.58,41.65,47.04,,41.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,42.63,,,percent of total billed charges,,,,,,,,,44.1,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TOBRAMYCIN TROUGH,3076304,CDM,301,RC,80200,CPT,,,,,,outpatient,facility,,,49,20.58,13.23,47.04,,41.65,,,percent of total billed charges,,,13.23,,,percent of total billed charges,,,33.71,,,percent of total billed charges,,,32.98,,,percent of total billed charges,,,41.41,,,percent of total billed charges,,,16.13,,,fee schedule,,,42.63,,,percent of total billed charges,,,42.63,,,percent of total billed charges,,,41.65,,,percent of total billed charges,,,47.04,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,16.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",44.1,,,percent of total billed charges,,,16.13,,,fee schedule,,,45.57,,,percent of total billed charges,,,46.55,,,percent of total billed charges,,,23.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.78,,,fee schedule,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,14.03,,,fee schedule,,,16.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",38.27,,,percent of total billed charges,,,44.59,,,percent of total billed charges,,,16.13,,,fee schedule,,,16.13,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TOPIRAMATE,3076338,CDM,301,RC,80201,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TOPIRAMATE,3076338,CDM,301,RC,80201,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.92,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.92,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.09,,,fee schedule,,,10.58,,,fee schedule,,,10.58,,,fee schedule,,,10.37,,,fee schedule,,,11.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.92,,,fee schedule,,,11.92,,,fee schedule,,,14.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRANSFERRIN,3076353,CDM,301,RC,84466,CPT,,,,,,inpatient,facility,,,39,16.38,33.15,37.44,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.93,,,percent of total billed charges,,,,,,,,,35.1,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERRIN,3076353,CDM,301,RC,84466,CPT,,,,,,outpatient,facility,,,39,16.38,10.53,37.44,,33.15,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,32.95,,,percent of total billed charges,,,12.76,,,fee schedule,,,33.93,,,percent of total billed charges,,,33.93,,,percent of total billed charges,,,33.15,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,13.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.1,,,percent of total billed charges,,,12.76,,,fee schedule,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,18.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.23,,,fee schedule,,,11.33,,,fee schedule,,,11.33,,,fee schedule,,,11.1,,,fee schedule,,,12.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",30.46,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,12.76,,,fee schedule,,,12.76,,,fee schedule,,,14.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF TRAZODONE DAY,3076361,CDM,301,RC,80338,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF TRAZODONE DAY,3076361,CDM,301,RC,80338,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB TRIGLYCERIDES,3076395,CDM,301,RC,84478,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIGLYCERIDES,3076395,CDM,301,RC,84478,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.74,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.74,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.75,,,fee schedule,,,5.1,,,fee schedule,,,5.1,,,fee schedule,,,5,,,fee schedule,,,5.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.74,,,fee schedule,,,5.74,,,fee schedule,,,7.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRIGLYCERIDES FLUID BODY,3076403,CDM,301,RC,84478,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIGLYCERIDES FLUID BODY,3076403,CDM,301,RC,84478,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.74,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.74,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.75,,,fee schedule,,,5.1,,,fee schedule,,,5.1,,,fee schedule,,,5,,,fee schedule,,,5.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.74,,,fee schedule,,,5.74,,,fee schedule,,,7.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRIIODOTHYRONINE T3 FREE,3076411,CDM,301,RC,84481,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIIODOTHYRONINE T3 FREE,3076411,CDM,301,RC,84481,CPT,,,,,,outpatient,facility,,,54,22.68,14.58,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,16.94,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,17.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,16.94,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,24.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.87,,,fee schedule,,,15.04,,,fee schedule,,,15.04,,,fee schedule,,,14.74,,,fee schedule,,,16.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,16.94,,,fee schedule,,,16.94,,,fee schedule,,,20.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRIIODOTHYRONINE T3 REVERSE,3076429,CDM,301,RC,84482,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIIODOTHYRONINE T3 REVERSE,3076429,CDM,301,RC,84482,CPT,,,,,,outpatient,facility,,,59,24.78,13.71,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,15.76,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,15.76,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,22.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.28,,,fee schedule,,,13.99,,,fee schedule,,,13.99,,,fee schedule,,,13.71,,,fee schedule,,,15.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,15.76,,,fee schedule,,,15.76,,,fee schedule,,,19.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRIIODOTHYRONINE T3 TOTAL,3076437,CDM,301,RC,84480,CPT,,,,,,inpatient,facility,,,43,18.06,36.55,41.28,,36.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.41,,,percent of total billed charges,,,,,,,,,38.7,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIIODOTHYRONINE T3 TOTAL,3076437,CDM,301,RC,84480,CPT,,,,,,outpatient,facility,,,43,18.06,11.61,41.28,,36.55,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,29.58,,,percent of total billed charges,,,28.94,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,14.18,,,fee schedule,,,37.41,,,percent of total billed charges,,,37.41,,,percent of total billed charges,,,36.55,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,14.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",38.7,,,percent of total billed charges,,,14.18,,,fee schedule,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,20.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.14,,,fee schedule,,,12.59,,,fee schedule,,,12.59,,,fee schedule,,,12.34,,,fee schedule,,,14.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",33.58,,,percent of total billed charges,,,39.13,,,percent of total billed charges,,,14.18,,,fee schedule,,,14.18,,,fee schedule,,,17.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TROPONIN QN,3076460,CDM,301,RC,84484,CPT,,,,,,inpatient,facility,,,38,15.96,32.3,36.48,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,,,,,,,34.2,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TROPONIN QN,3076460,CDM,301,RC,84484,CPT,,,,,,outpatient,facility,,,38,15.96,8.21,36.48,,32.3,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,26.14,,,percent of total billed charges,,,25.57,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,12.47,,,fee schedule,,,33.06,,,percent of total billed charges,,,33.06,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,12.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.2,,,percent of total billed charges,,,12.47,,,fee schedule,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,18.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.83,,,fee schedule,,,11.07,,,fee schedule,,,11.07,,,fee schedule,,,10.85,,,fee schedule,,,12.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",29.68,,,percent of total billed charges,,,34.58,,,percent of total billed charges,,,12.47,,,fee schedule,,,12.47,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROID STIMULATING HORMONE,3076486,CDM,301,RC,84443,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROID STIMULATING HORMONE,3076486,CDM,301,RC,84443,CPT,,,,,,outpatient,facility,,,54,22.68,14.58,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,16.8,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,17.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,16.8,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,24.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.68,,,fee schedule,,,14.92,,,fee schedule,,,14.92,,,fee schedule,,,14.62,,,fee schedule,,,16.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,16.8,,,fee schedule,,,16.8,,,fee schedule,,,20.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TYROSINE,3076494,CDM,301,RC,84510,CPT,,,,,,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TYROSINE,3076494,CDM,301,RC,84510,CPT,,,,,,outpatient,facility,,,100,42,9.25,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,10.63,,,fee schedule,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,10.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90,,,percent of total billed charges,,,10.63,,,fee schedule,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,15.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.35,,,fee schedule,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,9.25,,,fee schedule,,,10.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,10.63,,,fee schedule,,,10.63,,,fee schedule,,,12.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NITROGEN UREA QN,3076510,CDM,301,RC,84520,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NITROGEN UREA QN,3076510,CDM,301,RC,84520,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,11.52,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.95,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.95,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.33,,,fee schedule,,,3.51,,,fee schedule,,,3.51,,,fee schedule,,,3.44,,,fee schedule,,,3.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NITROGEN UREA URINE,3076536,CDM,301,RC,84540,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NITROGEN UREA URINE,3076536,CDM,301,RC,84540,CPT,,,,,,outpatient,facility,,,52,21.84,4.84,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,5.56,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,5.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,5.56,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,8.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.51,,,fee schedule,,,4.94,,,fee schedule,,,4.94,,,fee schedule,,,4.84,,,fee schedule,,,5.56,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.56,,,fee schedule,,,5.56,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID URIC BLOOD,3076544,CDM,301,RC,84550,CPT,,,,,,inpatient,facility,,,14,5.88,11.9,13.44,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID URIC BLOOD,3076544,CDM,301,RC,84550,CPT,,,,,,outpatient,facility,,,14,5.88,3.78,13.44,,11.9,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.52,,,fee schedule,,,12.18,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,11.9,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,4.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.6,,,percent of total billed charges,,,4.52,,,fee schedule,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,6.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.1,,,fee schedule,,,4.01,,,fee schedule,,,4.01,,,fee schedule,,,3.93,,,fee schedule,,,4.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.93,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,4.52,,,fee schedule,,,4.52,,,fee schedule,,,5.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID URIC FLUID BODY,3076551,CDM,301,RC,84560,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID URIC FLUID BODY,3076551,CDM,301,RC,84560,CPT,,,,,,outpatient,facility,,,56,23.52,4.42,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.08,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.08,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,7.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.86,,,fee schedule,,,4.51,,,fee schedule,,,4.51,,,fee schedule,,,4.42,,,fee schedule,,,5.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.08,,,fee schedule,,,5.08,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID URIC URINE,3076577,CDM,301,RC,84560,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID URIC URINE,3076577,CDM,301,RC,84560,CPT,,,,,,outpatient,facility,,,56,23.52,4.42,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.08,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.08,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,7.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.86,,,fee schedule,,,4.51,,,fee schedule,,,4.51,,,fee schedule,,,4.42,,,fee schedule,,,5.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.08,,,fee schedule,,,5.08,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VANCOMYCIN PEAK,3076619,CDM,301,RC,80202,CPT,,,,,,inpatient,facility,,,41,17.22,34.85,39.36,,34.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,36.9,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VANCOMYCIN PEAK,3076619,CDM,301,RC,80202,CPT,,,,,,outpatient,facility,,,41,17.22,11.07,39.36,,34.85,,,percent of total billed charges,,,11.07,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,34.64,,,percent of total billed charges,,,13.54,,,fee schedule,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,34.85,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.9,,,percent of total billed charges,,,13.54,,,fee schedule,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,19.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.28,,,fee schedule,,,12.02,,,fee schedule,,,12.02,,,fee schedule,,,11.78,,,fee schedule,,,13.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.02,,,percent of total billed charges,,,37.31,,,percent of total billed charges,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,16.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VANCOMYCIN RANDOM,3076627,CDM,301,RC,80202,CPT,,,,,,inpatient,facility,,,41,17.22,34.85,39.36,,34.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,36.9,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VANCOMYCIN RANDOM,3076627,CDM,301,RC,80202,CPT,,,,,,outpatient,facility,,,41,17.22,11.07,39.36,,34.85,,,percent of total billed charges,,,11.07,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,34.64,,,percent of total billed charges,,,13.54,,,fee schedule,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,34.85,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.9,,,percent of total billed charges,,,13.54,,,fee schedule,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,19.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.28,,,fee schedule,,,12.02,,,fee schedule,,,12.02,,,fee schedule,,,11.78,,,fee schedule,,,13.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.02,,,percent of total billed charges,,,37.31,,,percent of total billed charges,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,16.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VANCOMYCIN TROUGH,3076635,CDM,301,RC,80202,CPT,,,,,,inpatient,facility,,,41,17.22,34.85,39.36,,34.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,36.9,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VANCOMYCIN TROUGH,3076635,CDM,301,RC,80202,CPT,,,,,,outpatient,facility,,,41,17.22,11.07,39.36,,34.85,,,percent of total billed charges,,,11.07,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,34.64,,,percent of total billed charges,,,13.54,,,fee schedule,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,34.85,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.9,,,percent of total billed charges,,,13.54,,,fee schedule,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,19.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.28,,,fee schedule,,,12.02,,,fee schedule,,,12.02,,,fee schedule,,,11.78,,,fee schedule,,,13.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.02,,,percent of total billed charges,,,37.31,,,percent of total billed charges,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,16.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID VANILLYLMANDELIC URINE,3076643,CDM,301,RC,84585,CPT,,,,,,inpatient,facility,,,82,34.44,69.7,78.72,,69.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.34,,,percent of total billed charges,,,,,,,,,73.8,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID VANILLYLMANDELIC URINE,3076643,CDM,301,RC,84585,CPT,,,,,,outpatient,facility,,,82,34.44,13.48,78.72,,69.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,55.19,,,percent of total billed charges,,,69.29,,,percent of total billed charges,,,15.5,,,fee schedule,,,71.34,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,69.7,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,15.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",73.8,,,percent of total billed charges,,,15.5,,,fee schedule,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,22.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.93,,,fee schedule,,,13.76,,,fee schedule,,,13.76,,,fee schedule,,,13.48,,,fee schedule,,,15.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.04,,,percent of total billed charges,,,74.62,,,percent of total billed charges,,,15.5,,,fee schedule,,,15.5,,,fee schedule,,,19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VASOACTIVE INTS PEPTIDE NS,3076650,CDM,301,RC,84586,CPT,,,,,,inpatient,facility,,,160,67.2,136,153.6,,136,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.2,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VASOACTIVE INTS PEPTIDE NS,3076650,CDM,301,RC,84586,CPT,,,,,,outpatient,facility,,,160,67.2,30.74,153.6,,136,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,110.08,,,percent of total billed charges,,,107.68,,,percent of total billed charges,,,135.2,,,percent of total billed charges,,,35.33,,,fee schedule,,,139.2,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,136,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,36.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",144,,,percent of total billed charges,,,35.33,,,fee schedule,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,51.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,fee schedule,,,31.37,,,fee schedule,,,31.37,,,fee schedule,,,30.74,,,fee schedule,,,35.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",124.96,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,35.33,,,fee schedule,,,35.33,,,fee schedule,,,43.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VASOPRESSIN,3076668,CDM,301,RC,84588,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VASOPRESSIN,3076668,CDM,301,RC,84588,CPT,,,,,,outpatient,facility,,,102,42.84,27.54,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,33.94,,,fee schedule,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,34.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",91.8,,,percent of total billed charges,,,33.94,,,fee schedule,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,49.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.82,,,fee schedule,,,30.14,,,fee schedule,,,30.14,,,fee schedule,,,29.54,,,fee schedule,,,33.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,33.94,,,fee schedule,,,33.94,,,fee schedule,,,41.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB RIBOFLAVIN,3076700,CDM,301,RC,84252,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RIBOFLAVIN,3076700,CDM,301,RC,84252,CPT,,,,,,outpatient,facility,,,74,31.08,17.61,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,20.24,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,20.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,20.24,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,29.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.32,,,fee schedule,,,17.97,,,fee schedule,,,17.97,,,fee schedule,,,17.61,,,fee schedule,,,20.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,20.24,,,fee schedule,,,20.24,,,fee schedule,,,24.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PYRIDOXAL PHOSPHATE,3076718,CDM,301,RC,84207,CPT,,,,,,inpatient,facility,,,85,35.7,72.25,81.6,,72.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,,,,,,,,76.5,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PYRIDOXAL PHOSPHATE,3076718,CDM,301,RC,84207,CPT,,,,,,outpatient,facility,,,85,35.7,22.95,81.6,,72.25,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,58.48,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,71.83,,,percent of total billed charges,,,28.1,,,fee schedule,,,73.95,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,72.25,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,28.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",76.5,,,percent of total billed charges,,,28.1,,,fee schedule,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,40.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.94,,,fee schedule,,,24.95,,,fee schedule,,,24.95,,,fee schedule,,,24.45,,,fee schedule,,,28.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",66.38,,,percent of total billed charges,,,77.35,,,percent of total billed charges,,,28.1,,,fee schedule,,,28.1,,,fee schedule,,,34.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID ASCORBIC BLOOD,3076726,CDM,301,RC,82180,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID ASCORBIC BLOOD,3076726,CDM,301,RC,82180,CPT,,,,,,outpatient,facility,,,59,24.78,8.41,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,9.89,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,10.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,9.89,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,14.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.35,,,fee schedule,,,8.78,,,fee schedule,,,8.78,,,fee schedule,,,8.6,,,fee schedule,,,9.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,9.89,,,fee schedule,,,9.89,,,fee schedule,,,8.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VITAMIN D 1 25 DIHYDROXY FRAC,3076734,CDM,301,RC,82652,CPT,,,,,,inpatient,facility,,,116,48.72,98.6,111.36,,98.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,104.4,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VITAMIN D 1 25 DIHYDROXY FRAC,3076734,CDM,301,RC,82652,CPT,,,,,,outpatient,facility,,,116,48.72,31.32,111.36,,98.6,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,79.81,,,percent of total billed charges,,,78.07,,,percent of total billed charges,,,98.02,,,percent of total billed charges,,,38.5,,,fee schedule,,,100.92,,,percent of total billed charges,,,100.92,,,percent of total billed charges,,,98.6,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,39.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",104.4,,,percent of total billed charges,,,38.5,,,fee schedule,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,55.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.98,,,fee schedule,,,34.19,,,fee schedule,,,34.19,,,fee schedule,,,33.51,,,fee schedule,,,38.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",90.6,,,percent of total billed charges,,,105.56,,,percent of total billed charges,,,38.5,,,fee schedule,,,38.5,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VITAMIN D 25 HYDROXY W FRAC NS,3076759,CDM,301,RC,82306,CPT,,,,,,inpatient,facility,,,89,37.38,75.65,85.44,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,,,,,,,80.1,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VITAMIN D 25 HYDROXY W FRAC NS,3076759,CDM,301,RC,82306,CPT,,,,,,outpatient,facility,,,89,37.38,24.03,85.44,,75.65,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,61.23,,,percent of total billed charges,,,59.9,,,percent of total billed charges,,,75.2,,,percent of total billed charges,,,29.6,,,fee schedule,,,77.43,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,75.65,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,30.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",80.1,,,percent of total billed charges,,,29.6,,,fee schedule,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,42.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.96,,,fee schedule,,,26.28,,,fee schedule,,,26.28,,,fee schedule,,,25.75,,,fee schedule,,,29.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",69.51,,,percent of total billed charges,,,80.99,,,percent of total billed charges,,,29.6,,,fee schedule,,,29.6,,,fee schedule,,,36.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TOCOPHEROL ALPHA,3076767,CDM,301,RC,84446,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TOCOPHEROL ALPHA,3076767,CDM,301,RC,84446,CPT,,,,,,outpatient,facility,,,62,26.04,12.34,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,14.18,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,14.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,14.18,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,20.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.14,,,fee schedule,,,12.59,,,fee schedule,,,12.59,,,fee schedule,,,12.34,,,fee schedule,,,14.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,14.18,,,fee schedule,,,14.18,,,fee schedule,,,17.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VITAMIN A,3076775,CDM,301,RC,84590,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VITAMIN A,3076775,CDM,301,RC,84590,CPT,,,,,,outpatient,facility,,,62,26.04,10.1,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,11.61,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,11.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,11.61,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,16.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.67,,,fee schedule,,,10.31,,,fee schedule,,,10.31,,,fee schedule,,,10.1,,,fee schedule,,,11.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,11.61,,,fee schedule,,,11.61,,,fee schedule,,,12.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THIAMINE,3076783,CDM,301,RC,84425,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THIAMINE,3076783,CDM,301,RC,84425,CPT,,,,,,outpatient,facility,,,64,26.88,17.28,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,21.23,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,21.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,21.23,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,30.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.66,,,fee schedule,,,18.85,,,fee schedule,,,18.85,,,fee schedule,,,18.47,,,fee schedule,,,21.23,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,21.23,,,fee schedule,,,21.23,,,fee schedule,,,26.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYANOCOBALAMIN,3076791,CDM,301,RC,82607,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYANOCOBALAMIN,3076791,CDM,301,RC,82607,CPT,,,,,,outpatient,facility,,,54,22.68,13.12,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,15.08,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,15.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,15.08,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,21.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.36,,,fee schedule,,,13.39,,,fee schedule,,,13.39,,,fee schedule,,,13.12,,,fee schedule,,,15.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,15.08,,,fee schedule,,,15.08,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VITAMIN K,3076809,CDM,301,RC,84597,CPT,,,,,,inpatient,facility,,,85,35.7,72.25,81.6,,72.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,,,,,,,,76.5,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VITAMIN K,3076809,CDM,301,RC,84597,CPT,,,,,,outpatient,facility,,,85,35.7,11.94,81.6,,72.25,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,58.48,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,71.83,,,percent of total billed charges,,,13.72,,,fee schedule,,,73.95,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,72.25,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,13.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",76.5,,,percent of total billed charges,,,13.72,,,fee schedule,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,19.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.52,,,fee schedule,,,12.18,,,fee schedule,,,12.18,,,fee schedule,,,11.94,,,fee schedule,,,13.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",66.38,,,percent of total billed charges,,,77.35,,,percent of total billed charges,,,13.72,,,fee schedule,,,13.72,,,fee schedule,,,16.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT WB W INTRP ID BAND,3076833,CDM,301,RC,84182,CPT,,,,,,inpatient,facility,,,89,37.38,75.65,85.44,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,,,,,,,80.1,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT WB W INTRP ID BAND,3076833,CDM,301,RC,84182,CPT,,,,,,outpatient,facility,,,89,37.38,22.06,85.44,,75.65,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,61.23,,,percent of total billed charges,,,59.9,,,percent of total billed charges,,,75.2,,,percent of total billed charges,,,29.21,,,fee schedule,,,77.43,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,75.65,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,29.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",80.1,,,percent of total billed charges,,,29.21,,,fee schedule,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,42.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.43,,,fee schedule,,,25.94,,,fee schedule,,,25.94,,,fee schedule,,,25.42,,,fee schedule,,,29.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",69.51,,,percent of total billed charges,,,80.99,,,percent of total billed charges,,,29.21,,,fee schedule,,,29.21,,,fee schedule,,,22.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT WB W INTRP,3076841,CDM,301,RC,84181,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT WB W INTRP,3076841,CDM,301,RC,84181,CPT,,,,,,outpatient,facility,,,104,43.68,14.82,99.84,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,17.03,,,fee schedule,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",93.6,,,percent of total billed charges,,,17.03,,,fee schedule,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,24.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.99,,,fee schedule,,,15.12,,,fee schedule,,,15.12,,,fee schedule,,,14.82,,,fee schedule,,,17.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,17.03,,,fee schedule,,,17.03,,,fee schedule,,,20.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ZINC NS,3076874,CDM,301,RC,84630,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ZINC NS,3076874,CDM,301,RC,84630,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.39,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.39,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.38,,,fee schedule,,,10.11,,,fee schedule,,,10.11,,,fee schedule,,,9.91,,,fee schedule,,,11.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.39,,,fee schedule,,,11.39,,,fee schedule,,,13.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ADENOVIRUS,3076924,CDM,302,RC,86603,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ADENOVIRUS,3076924,CDM,302,RC,86603,CPT,,,,,,outpatient,facility,,,61,25.62,5.81,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,12.87,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,13.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,12.87,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,18.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.37,,,fee schedule,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,11.2,,,fee schedule,,,12.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,12.87,,,fee schedule,,,12.87,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AGGLUTININS FEBRILE AG EA,3076940,CDM,302,RC,86000,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AGGLUTININS FEBRILE AG EA,3076940,CDM,302,RC,86000,CPT,,,,,,outpatient,facility,,,21,8.82,4.17,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.98,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,7.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.98,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,10.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.42,,,fee schedule,,,6.2,,,fee schedule,,,6.2,,,fee schedule,,,6.08,,,fee schedule,,,6.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.98,,,fee schedule,,,6.98,,,fee schedule,,,4.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB AMOEBIC,3076965,CDM,302,RC,86753,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB AMOEBIC,3076965,CDM,302,RC,86753,CPT,,,,,,outpatient,facility,,,65,27.3,10.78,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,12.39,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,12.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,12.39,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,17.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.73,,,fee schedule,,,11,,,fee schedule,,,11,,,fee schedule,,,10.78,,,fee schedule,,,12.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,12.39,,,fee schedule,,,12.39,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR ANA,3076973,CDM,302,RC,86038,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR ANA,3076973,CDM,302,RC,86038,CPT,,,,,,outpatient,facility,,,53,22.26,10.53,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,12.09,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,12.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,12.09,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,17.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.32,,,fee schedule,,,10.74,,,fee schedule,,,10.74,,,fee schedule,,,10.53,,,fee schedule,,,12.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,12.09,,,fee schedule,,,12.09,,,fee schedule,,,10.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANA TITER,3076981,CDM,302,RC,86039,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANA TITER,3076981,CDM,302,RC,86039,CPT,,,,,,outpatient,facility,,,59,24.78,9.71,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,11.16,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,11.16,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.07,,,fee schedule,,,9.91,,,fee schedule,,,9.91,,,fee schedule,,,9.71,,,fee schedule,,,11.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,11.16,,,fee schedule,,,11.16,,,fee schedule,,,13.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANTISTREPTOLYSIN O TITER,3077005,CDM,302,RC,86060,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANTISTREPTOLYSIN O TITER,3077005,CDM,302,RC,86060,CPT,,,,,,outpatient,facility,,,57,23.94,6.35,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,7.3,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,7.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,7.3,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,10.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.86,,,fee schedule,,,6.48,,,fee schedule,,,6.48,,,fee schedule,,,6.35,,,fee schedule,,,7.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,7.3,,,fee schedule,,,7.3,,,fee schedule,,,8.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ASPERGILLUS,3077013,CDM,302,RC,86606,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ASPERGILLUS,3077013,CDM,302,RC,86606,CPT,,,,,,outpatient,facility,,,55,23.1,7.14,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,15.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,15.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,15.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.32,,,fee schedule,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,13.09,,,fee schedule,,,15.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,15.05,,,fee schedule,,,15.05,,,fee schedule,,,7.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB BARTONELLA,3077039,CDM,302,RC,86611,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB BARTONELLA,3077039,CDM,302,RC,86611,CPT,,,,,,outpatient,facility,,,62,26.04,5.81,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,10.18,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,10.18,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,14.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.74,,,fee schedule,,,9.04,,,fee schedule,,,9.04,,,fee schedule,,,8.86,,,fee schedule,,,10.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,10.18,,,fee schedule,,,10.18,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB BETA 2 GLYCOPROTEIN I,3077047,CDM,302,RC,86146,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB BETA 2 GLYCOPROTEIN I,3077047,CDM,302,RC,86146,CPT,,,,,,outpatient,facility,,,77,32.34,20.79,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,25.45,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,25.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,25.45,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,36.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.36,,,fee schedule,,,22.6,,,fee schedule,,,22.6,,,fee schedule,,,22.15,,,fee schedule,,,25.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,25.45,,,fee schedule,,,25.45,,,fee schedule,,,26.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB BLASTOMYCES NS,3077054,CDM,302,RC,86612,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB BLASTOMYCES NS,3077054,CDM,302,RC,86612,CPT,,,,,,outpatient,facility,,,78,32.76,5.81,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,12.9,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,13.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,12.9,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,18.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.42,,,fee schedule,,,11.46,,,fee schedule,,,11.46,,,fee schedule,,,11.23,,,fee schedule,,,12.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,12.9,,,fee schedule,,,12.9,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE ABO,3077070,CDM,300,RC,86900,CPT,,,,,,inpatient,facility,,,349,146.58,296.65,335.04,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.63,,,percent of total billed charges,,,,,,,,,314.1,,,percent of total billed charges,,,335.04,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,324.57,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE ABO,3077070,CDM,300,RC,86900,CPT,,,,,,outpatient,facility,,,349,146.58,94.23,335.04,,296.65,,,percent of total billed charges,,,94.23,,,percent of total billed charges,,,240.11,,,percent of total billed charges,,,234.88,,,percent of total billed charges,,,294.9,,,percent of total billed charges,,,,,,,,,303.63,,,percent of total billed charges,,,303.63,,,percent of total billed charges,,,296.65,,,percent of total billed charges,,,335.04,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,314.1,,,percent of total billed charges,,,,,,,,,324.57,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,127.74,,,fee schedule,,,,,,,,,272.57,,,percent of total billed charges,,,317.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE ABO,3077070,CDM,300,RC,86900,CPT,5734,APC,,,,outpatient,facility,,,349,349,63.07,189.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,189.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,130.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,63.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE RHD,3077088,CDM,300,RC,86901,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE RHD,3077088,CDM,300,RC,86901,CPT,,,,,,outpatient,facility,,,102,42.84,27.54,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,40.1,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE RHD,3077088,CDM,300,RC,86901,CPT,5732,APC,,,,outpatient,facility,,,102,102,18.45,59.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,59.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,18.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB BORDETELLA,3077104,CDM,302,RC,86615,CPT,,,,,,inpatient,facility,,,70,29.4,59.5,67.2,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.9,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB BORDETELLA,3077104,CDM,302,RC,86615,CPT,,,,,,outpatient,facility,,,70,29.4,11.48,67.2,,59.5,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,47.11,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.19,,,fee schedule,,,60.9,,,percent of total billed charges,,,60.9,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63,,,percent of total billed charges,,,13.19,,,fee schedule,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",54.67,,,percent of total billed charges,,,63.7,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB BRUCELLA,3077112,CDM,302,RC,86622,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB BRUCELLA,3077112,CDM,302,RC,86622,CPT,,,,,,outpatient,facility,,,67,28.14,6.69,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,8.93,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,9.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,8.93,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,12.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.06,,,fee schedule,,,7.93,,,fee schedule,,,7.93,,,fee schedule,,,7.77,,,fee schedule,,,8.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,8.93,,,fee schedule,,,8.93,,,fee schedule,,,6.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CANDIDA,3077138,CDM,302,RC,86628,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CANDIDA,3077138,CDM,302,RC,86628,CPT,,,,,,outpatient,facility,,,71,29.82,7.14,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,12.01,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,12.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,12.01,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,17.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.21,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,12.01,,,fee schedule,,,12.01,,,fee schedule,,,7.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CARDIOLIPIN IG EA,3077146,CDM,302,RC,86147,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CARDIOLIPIN IG EA,3077146,CDM,302,RC,86147,CPT,,,,,,outpatient,facility,,,80,33.6,21.6,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,25.45,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,25.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,25.45,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,36.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.36,,,fee schedule,,,22.6,,,fee schedule,,,22.6,,,fee schedule,,,22.15,,,fee schedule,,,25.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,25.45,,,fee schedule,,,25.45,,,fee schedule,,,26.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHLAMYDIA,3077153,CDM,302,RC,86631,CPT,,,,,,inpatient,facility,,,81,34.02,68.85,77.76,,68.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.47,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHLAMYDIA,3077153,CDM,302,RC,86631,CPT,,,,,,outpatient,facility,,,81,34.02,10.29,77.76,,68.85,,,percent of total billed charges,,,21.87,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,54.51,,,percent of total billed charges,,,68.44,,,percent of total billed charges,,,11.82,,,fee schedule,,,70.47,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,12.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72.9,,,percent of total billed charges,,,11.82,,,fee schedule,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,17.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.96,,,fee schedule,,,10.5,,,fee schedule,,,10.5,,,fee schedule,,,10.29,,,fee schedule,,,11.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",63.26,,,percent of total billed charges,,,73.71,,,percent of total billed charges,,,11.82,,,fee schedule,,,11.82,,,fee schedule,,,14.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHLAMYDIA PNEU IGG IGA,3077179,CDM,302,RC,86631,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHLAMYDIA PNEU IGG IGA,3077179,CDM,302,RC,86631,CPT,,,,,,outpatient,facility,,,61,25.62,10.29,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,11.82,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,11.82,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,17.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.96,,,fee schedule,,,10.5,,,fee schedule,,,10.5,,,fee schedule,,,10.29,,,fee schedule,,,11.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,11.82,,,fee schedule,,,11.82,,,fee schedule,,,14.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHLAMYDIA PNEUM IGM,3077187,CDM,302,RC,86632,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHLAMYDIA PNEUM IGM,3077187,CDM,302,RC,86632,CPT,,,,,,outpatient,facility,,,61,25.62,11.03,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,12.68,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,12.68,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,18.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.12,,,fee schedule,,,11.26,,,fee schedule,,,11.26,,,fee schedule,,,11.03,,,fee schedule,,,12.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,12.68,,,fee schedule,,,12.68,,,fee schedule,,,15.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHLAMYDIA PSITTACI IGG IGA,3077195,CDM,302,RC,86631,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHLAMYDIA PSITTACI IGG IGA,3077195,CDM,302,RC,86631,CPT,,,,,,outpatient,facility,,,61,25.62,10.29,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,11.82,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,11.82,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,17.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.96,,,fee schedule,,,10.5,,,fee schedule,,,10.5,,,fee schedule,,,10.29,,,fee schedule,,,11.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,11.82,,,fee schedule,,,11.82,,,fee schedule,,,14.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHLAMYDIA PSITTACI IGM,3077203,CDM,302,RC,86632,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHLAMYDIA PSITTACI IGM,3077203,CDM,302,RC,86632,CPT,,,,,,outpatient,facility,,,61,25.62,11.03,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,12.68,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,12.68,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,18.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.12,,,fee schedule,,,11.26,,,fee schedule,,,11.26,,,fee schedule,,,11.03,,,fee schedule,,,12.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,12.68,,,fee schedule,,,12.68,,,fee schedule,,,15.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHLAMYDIA TRAC IGM,3077211,CDM,302,RC,86632,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHLAMYDIA TRAC IGM,3077211,CDM,302,RC,86632,CPT,,,,,,outpatient,facility,,,61,25.62,11.03,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,12.68,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,12.68,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,18.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.12,,,fee schedule,,,11.26,,,fee schedule,,,11.26,,,fee schedule,,,11.03,,,fee schedule,,,12.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,12.68,,,fee schedule,,,12.68,,,fee schedule,,,15.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CYTOMEGALOVIRUS,3077229,CDM,302,RC,86644,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CYTOMEGALOVIRUS,3077229,CDM,302,RC,86644,CPT,,,,,,outpatient,facility,,,60,25.2,12.52,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,14.39,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,14.39,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CYTOMEGALOVIRUS IGM,3077237,CDM,302,RC,86645,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CYTOMEGALOVIRUS IGM,3077237,CDM,302,RC,86645,CPT,,,,,,outpatient,facility,,,61,25.62,14.66,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,16.85,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,17.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,16.85,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,24.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.75,,,fee schedule,,,14.96,,,fee schedule,,,14.96,,,fee schedule,,,14.66,,,fee schedule,,,16.85,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,16.85,,,fee schedule,,,16.85,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CYTOMEGALOVIRUS IGM NS,3077245,CDM,302,RC,86645,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CYTOMEGALOVIRUS IGM NS,3077245,CDM,302,RC,86645,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.85,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.85,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.75,,,fee schedule,,,14.96,,,fee schedule,,,14.96,,,fee schedule,,,14.66,,,fee schedule,,,16.85,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.85,,,fee schedule,,,16.85,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB COCCIDIOIDES,3077252,CDM,302,RC,86635,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB COCCIDIOIDES,3077252,CDM,302,RC,86635,CPT,,,,,,outpatient,facility,,,55,23.1,5.81,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,11.47,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,11.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,11.47,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,16.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.48,,,fee schedule,,,10.19,,,fee schedule,,,10.19,,,fee schedule,,,9.99,,,fee schedule,,,11.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,11.47,,,fee schedule,,,11.47,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB COCCIDIOIDES IGG,3077260,CDM,302,RC,86635,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB COCCIDIOIDES IGG,3077260,CDM,302,RC,86635,CPT,,,,,,outpatient,facility,,,63,26.46,5.81,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,11.47,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,11.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,11.47,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,16.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.48,,,fee schedule,,,10.19,,,fee schedule,,,10.19,,,fee schedule,,,9.99,,,fee schedule,,,11.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,11.47,,,fee schedule,,,11.47,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB COCCIDIOIDES IGM,3077278,CDM,302,RC,86635,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB COCCIDIOIDES IGM,3077278,CDM,302,RC,86635,CPT,,,,,,outpatient,facility,,,63,26.46,5.81,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,11.47,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,11.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,11.47,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,16.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.48,,,fee schedule,,,10.19,,,fee schedule,,,10.19,,,fee schedule,,,9.99,,,fee schedule,,,11.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,11.47,,,fee schedule,,,11.47,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AGGLUTININ COLD,3077286,CDM,302,RC,86156,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AGGLUTININ COLD,3077286,CDM,302,RC,86156,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.07,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.07,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.89,,,fee schedule,,,7.17,,,fee schedule,,,7.17,,,fee schedule,,,7.03,,,fee schedule,,,8.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.07,,,fee schedule,,,8.07,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AGGLUTININ COLD TITER,3077294,CDM,302,RC,86157,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AGGLUTININ COLD TITER,3077294,CDM,302,RC,86157,CPT,,,,,,outpatient,facility,,,58,24.36,7.02,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,8.06,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,8.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,8.06,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,11.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.88,,,fee schedule,,,7.16,,,fee schedule,,,7.16,,,fee schedule,,,7.02,,,fee schedule,,,8.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,8.06,,,fee schedule,,,8.06,,,fee schedule,,,9.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT ACT FUNC C1 ESTER,3077377,CDM,302,RC,86161,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT ACT FUNC C1 ESTER,3077377,CDM,302,RC,86161,CPT,,,,,,outpatient,facility,,,66,27.72,10.45,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,12,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,12,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT AG C1Q COMP EA,3077385,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG C1Q COMP EA,3077385,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,76,31.92,10.45,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,12,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,12,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT AG C2 COMP EA,3077393,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG C2 COMP EA,3077393,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,12,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,12,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT AG C3 COMP EA,3077401,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG C3 COMP EA,3077401,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,12,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,12,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT AG C4 COMP EA,3077419,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG C4 COMP EA,3077419,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,53,22.26,10.45,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,12,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,12,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT AG C5 COMP EA,3077427,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG C5 COMP EA,3077427,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,77,32.34,10.45,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,12,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,12,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT ACT FUNC,3077468,CDM,302,RC,86161,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT ACT FUNC,3077468,CDM,302,RC,86161,CPT,,,,,,outpatient,facility,,,66,27.72,10.45,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,12,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,12,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT TOTAL HEMOLYTIC,3077484,CDM,302,RC,86162,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT TOTAL HEMOLYTIC,3077484,CDM,302,RC,86162,CPT,,,,,,outpatient,facility,,,61,25.62,16.47,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,20.32,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,20.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,20.32,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,29.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.43,,,fee schedule,,,18.04,,,fee schedule,,,18.04,,,fee schedule,,,17.68,,,fee schedule,,,20.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,20.32,,,fee schedule,,,20.32,,,fee schedule,,,24.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COOMBS INDIRECT TITER AB EA NS,3077492,CDM,302,RC,86886,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COOMBS INDIRECT TITER AB EA NS,3077492,CDM,302,RC,86886,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB COOMBS INDIRECT TITER AB EA NS,3077492,CDM,302,RC,86886,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COOMBS INDIRECT TITER AB EA,3077500,CDM,302,RC,86886,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COOMBS INDIRECT TITER AB EA,3077500,CDM,302,RC,86886,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB COOMBS INDIRECT TITER AB EA,3077500,CDM,302,RC,86886,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB COXIELLA BRUNETII,3077526,CDM,302,RC,86638,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB COXIELLA BRUNETII,3077526,CDM,302,RC,86638,CPT,,,,,,outpatient,facility,,,57,23.94,5.81,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,12.12,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,12.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,12.12,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,17.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.36,,,fee schedule,,,10.76,,,fee schedule,,,10.76,,,fee schedule,,,10.54,,,fee schedule,,,12.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,12.12,,,fee schedule,,,12.12,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB COXSACKIE,3077534,CDM,302,RC,86658,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB COXSACKIE,3077534,CDM,302,RC,86658,CPT,,,,,,outpatient,facility,,,53,22.26,5.81,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,13.03,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,13.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,13.03,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,18.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.59,,,fee schedule,,,11.57,,,fee schedule,,,11.57,,,fee schedule,,,11.34,,,fee schedule,,,13.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,13.03,,,fee schedule,,,13.03,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT C REACTIVE SENS HIGH,3077542,CDM,302,RC,86141,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT C REACTIVE SENS HIGH,3077542,CDM,302,RC,86141,CPT,,,,,,outpatient,facility,,,57,23.94,11.27,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,12.95,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,13.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,12.95,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,18.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.48,,,fee schedule,,,11.5,,,fee schedule,,,11.5,,,fee schedule,,,11.27,,,fee schedule,,,12.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,12.95,,,fee schedule,,,12.95,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT C REACTIVE,3077559,CDM,302,RC,86140,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT C REACTIVE,3077559,CDM,302,RC,86140,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.18,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.18,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CROSSMATCH ANTIGLOBULIN,3077567,CDM,300,RC,86922,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH ANTIGLOBULIN,3077567,CDM,300,RC,86922,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH ANTIGLOBULIN,3077567,CDM,300,RC,86922,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CROSSMATCH SPIN IMMEDIATE,3077575,CDM,300,RC,86920,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH SPIN IMMEDIATE,3077575,CDM,300,RC,86920,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH SPIN IMMEDIATE,3077575,CDM,300,RC,86920,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CROSSMATCH INCUBATION,3077583,CDM,300,RC,86921,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH INCUBATION,3077583,CDM,300,RC,86921,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH INCUBATION,3077583,CDM,300,RC,86921,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR SERUM PRA CYTOTOXIC QUICK,3077609,CDM,302,RC,86808,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR SERUM PRA CYTOTOXIC QUICK,3077609,CDM,302,RC,86808,CPT,,,,,,outpatient,facility,,,90,37.8,24.3,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,29.68,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,30.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,29.68,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,43.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",40.07,,,fee schedule,,,26.36,,,fee schedule,,,26.36,,,fee schedule,,,25.83,,,fee schedule,,,29.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,29.68,,,fee schedule,,,29.68,,,fee schedule,,,36.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB DEOXYRIBONUCLEASE,3077617,CDM,302,RC,86215,CPT,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB DEOXYRIBONUCLEASE,3077617,CDM,302,RC,86215,CPT,,,,,,outpatient,facility,,,40,16.8,10.8,38.4,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,13.25,,,fee schedule,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36,,,percent of total billed charges,,,13.25,,,fee schedule,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,16.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB DIPTHERIA,3077625,CDM,302,RC,86648,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB DIPTHERIA,3077625,CDM,302,RC,86648,CPT,,,,,,outpatient,facility,,,63,26.46,13.24,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,15.21,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,15.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,15.21,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,22.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.53,,,fee schedule,,,13.51,,,fee schedule,,,13.51,,,fee schedule,,,13.24,,,fee schedule,,,15.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,15.21,,,fee schedule,,,15.21,,,fee schedule,,,18.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB DNA STRANDED NATVE DOUBLE,3077633,CDM,302,RC,86225,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB DNA STRANDED NATVE DOUBLE,3077633,CDM,302,RC,86225,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.74,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,14.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.74,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,19.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.55,,,fee schedule,,,12.2,,,fee schedule,,,12.2,,,fee schedule,,,11.96,,,fee schedule,,,13.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.74,,,fee schedule,,,13.74,,,fee schedule,,,16.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EBV EARLY AG,3077658,CDM,302,RC,86663,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EBV EARLY AG,3077658,CDM,302,RC,86663,CPT,,,,,,outpatient,facility,,,55,23.1,11.42,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,13.12,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,13.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,13.12,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,19.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.71,,,fee schedule,,,11.65,,,fee schedule,,,11.65,,,fee schedule,,,11.42,,,fee schedule,,,13.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,13.12,,,fee schedule,,,13.12,,,fee schedule,,,16.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EBV EBNA,3077666,CDM,302,RC,86664,CPT,,,,,,inpatient,facility,,,46,19.32,39.1,44.16,,39.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.02,,,percent of total billed charges,,,,,,,,,41.4,,,percent of total billed charges,,,44.16,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,42.78,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EBV EBNA,3077666,CDM,302,RC,86664,CPT,,,,,,outpatient,facility,,,46,19.32,12.42,44.16,,39.1,,,percent of total billed charges,,,12.42,,,percent of total billed charges,,,31.65,,,percent of total billed charges,,,30.96,,,percent of total billed charges,,,38.87,,,percent of total billed charges,,,15.29,,,fee schedule,,,40.02,,,percent of total billed charges,,,40.02,,,percent of total billed charges,,,39.1,,,percent of total billed charges,,,44.16,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,15.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.4,,,percent of total billed charges,,,15.29,,,fee schedule,,,42.78,,,percent of total billed charges,,,43.7,,,percent of total billed charges,,,22.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.64,,,fee schedule,,,13.58,,,fee schedule,,,13.58,,,fee schedule,,,13.31,,,fee schedule,,,15.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",35.93,,,percent of total billed charges,,,41.86,,,percent of total billed charges,,,15.29,,,fee schedule,,,15.29,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EBV VCA IGG,3077674,CDM,302,RC,86665,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EBV VCA IGG,3077674,CDM,302,RC,86665,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,18.14,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,18.14,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.49,,,fee schedule,,,16.11,,,fee schedule,,,16.11,,,fee schedule,,,15.79,,,fee schedule,,,18.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,18.14,,,fee schedule,,,18.14,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EBV VCA IGM,3077682,CDM,302,RC,86665,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EBV VCA IGM,3077682,CDM,302,RC,86665,CPT,,,,,,outpatient,facility,,,62,26.04,15.79,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,18.14,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,18.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,18.14,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,26.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.49,,,fee schedule,,,16.11,,,fee schedule,,,16.11,,,fee schedule,,,15.79,,,fee schedule,,,18.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,18.14,,,fee schedule,,,18.14,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EBV VCA,3077690,CDM,302,RC,86665,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EBV VCA,3077690,CDM,302,RC,86665,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,18.14,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,18.14,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.49,,,fee schedule,,,16.11,,,fee schedule,,,16.11,,,fee schedule,,,15.79,,,fee schedule,,,18.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,18.14,,,fee schedule,,,18.14,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EHRLICHIA,3077716,CDM,302,RC,86666,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EHRLICHIA,3077716,CDM,302,RC,86666,CPT,,,,,,outpatient,facility,,,80,33.6,5.81,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,10.18,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,10.18,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,14.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.74,,,fee schedule,,,9.04,,,fee schedule,,,9.04,,,fee schedule,,,8.86,,,fee schedule,,,10.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,10.18,,,fee schedule,,,10.18,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA RNP,3077732,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA RNP,3077732,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,17.93,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,17.93,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA SCLERODERMA,3077757,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,123,51.66,104.55,118.08,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.01,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA SCLERODERMA,3077757,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,123,51.66,15.6,118.08,,104.55,,,percent of total billed charges,,,33.21,,,percent of total billed charges,,,84.62,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,103.94,,,percent of total billed charges,,,17.93,,,fee schedule,,,107.01,,,percent of total billed charges,,,107.01,,,percent of total billed charges,,,104.55,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",110.7,,,percent of total billed charges,,,17.93,,,fee schedule,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.06,,,percent of total billed charges,,,111.93,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA SMITH,3077765,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA SMITH,3077765,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,17.93,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,17.93,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA SS A RO,3077773,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA SS A RO,3077773,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,17.93,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,17.93,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA SS B LA,3077781,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA SS B LA,3077781,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,17.93,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,17.93,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENCEPHALITIS CALIFORNIA,3077799,CDM,302,RC,86651,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENCEPHALITIS CALIFORNIA,3077799,CDM,302,RC,86651,CPT,,,,,,outpatient,facility,,,65,27.3,11.48,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.19,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.19,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENCEPHALITIS EQUINE EASTERN,3077807,CDM,302,RC,86652,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENCEPHALITIS EQUINE EASTERN,3077807,CDM,302,RC,86652,CPT,,,,,,outpatient,facility,,,65,27.3,11.48,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.19,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.19,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENCEPHALITIS SAINT LOUIS NS,3077815,CDM,302,RC,86653,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENCEPHALITIS SAINT LOUIS NS,3077815,CDM,302,RC,86653,CPT,,,,,,outpatient,facility,,,65,27.3,11.48,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.19,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.19,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENCEPHALITIS EQUINE WEST NS,3077823,CDM,302,RC,86654,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENCEPHALITIS EQUINE WEST NS,3077823,CDM,302,RC,86654,CPT,,,,,,outpatient,facility,,,65,27.3,11.48,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.19,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.19,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENTEROVIRUS,3077831,CDM,302,RC,86658,CPT,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENTEROVIRUS,3077831,CDM,302,RC,86658,CPT,,,,,,outpatient,facility,,,40,16.8,5.81,38.4,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,13.03,,,fee schedule,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,13.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36,,,percent of total billed charges,,,13.03,,,fee schedule,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,18.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.59,,,fee schedule,,,11.57,,,fee schedule,,,11.57,,,fee schedule,,,11.34,,,fee schedule,,,13.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,13.03,,,fee schedule,,,13.03,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THAWING PLASMA FRESH FROZEN,3077849,CDM,300,RC,86927,CPT,,,,,,inpatient,facility,,,489,205.38,415.65,469.44,,415.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.43,,,percent of total billed charges,,,,,,,,,440.1,,,percent of total billed charges,,,469.44,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.77,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THAWING PLASMA FRESH FROZEN,3077849,CDM,300,RC,86927,CPT,,,,,,outpatient,facility,,,489,205.38,132.03,469.44,,415.65,,,percent of total billed charges,,,132.03,,,percent of total billed charges,,,336.43,,,percent of total billed charges,,,329.1,,,percent of total billed charges,,,413.2,,,percent of total billed charges,,,,,,,,,425.43,,,percent of total billed charges,,,425.43,,,percent of total billed charges,,,415.65,,,percent of total billed charges,,,469.44,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,440.1,,,percent of total billed charges,,,,,,,,,454.77,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,381.91,,,percent of total billed charges,,,444.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB THAWING PLASMA FRESH FROZEN,3077849,CDM,300,RC,86927,CPT,5672,APC,,,,outpatient,facility,,,489,489,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB FL NS,3077856,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB FL NS,3077856,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,55,23.1,10.49,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,12.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB ENDOMYSIAL FL,3077906,CDM,302,RC,86231,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB ENDOMYSIAL FL,3077906,CDM,302,RC,86231,CPT,,,,,,outpatient,facility,,,61,25.62,10.53,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,12.09,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,12.09,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,17.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.32,,,fee schedule,,,10.74,,,fee schedule,,,10.74,,,fee schedule,,,10.53,,,fee schedule,,,12.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,12.09,,,fee schedule,,,12.09,,,fee schedule,,,10.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB PARIETAL FL,3077948,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB PARIETAL FL,3077948,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,55,23.1,10.49,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,12.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB RETICULUM FL,3077955,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB RETICULUM FL,3077955,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,54,22.68,10.49,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,12.05,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,12.05,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB MUSCLE SMOOTH FL,3077963,CDM,302,RC,86015,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB MUSCLE SMOOTH FL,3077963,CDM,302,RC,86015,CPT,,,,,,outpatient,facility,,,60,25.2,10.09,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,12.05,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,12.05,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,10.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB MUSCLE STRIATED FL,3077971,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB MUSCLE STRIATED FL,3077971,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,56,23.52,10.49,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,12.05,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,12.05,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER,3077989,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER,3077989,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.05,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER HU,3078011,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER HU,3078011,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,55,23.1,10.49,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,12.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER MITOCHONDRIA,3078029,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER MITOCHONDRIA,3078029,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,60,25.2,10.49,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,12.05,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,12.05,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER PARIETAL,3078045,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER PARIETAL,3078045,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,55,23.1,10.49,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,12.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER PURKINJE,3078052,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,190,79.8,161.5,182.4,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.3,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER PURKINJE,3078052,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,190,79.8,10.49,182.4,,161.5,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,130.72,,,percent of total billed charges,,,127.87,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,12.05,,,fee schedule,,,165.3,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",171,,,percent of total billed charges,,,12.05,,,fee schedule,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",148.39,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER MUSCLE SMOOTH,3078060,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER MUSCLE SMOOTH,3078060,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,65,27.3,10.49,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,12.05,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER MUSCLE STRIATED,3078078,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER MUSCLE STRIATED,3078078,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,65,27.3,10.49,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,12.05,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB FL,3078086,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,128,53.76,108.8,122.88,,108.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.36,,,percent of total billed charges,,,,,,,,,115.2,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB FL,3078086,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,128,53.76,10.49,122.88,,108.8,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,88.06,,,percent of total billed charges,,,86.14,,,percent of total billed charges,,,108.16,,,percent of total billed charges,,,12.05,,,fee schedule,,,111.36,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,108.8,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",115.2,,,percent of total billed charges,,,12.05,,,fee schedule,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.97,,,percent of total billed charges,,,116.48,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FRANCISELLA TULARENSIS,3078094,CDM,302,RC,86668,CPT,,,,,,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FRANCISELLA TULARENSIS,3078094,CDM,302,RC,86668,CPT,,,,,,outpatient,facility,,,100,42,10.65,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,14.16,,,fee schedule,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,14.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90,,,percent of total billed charges,,,14.16,,,fee schedule,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,20.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.12,,,fee schedule,,,12.57,,,fee schedule,,,12.57,,,fee schedule,,,12.32,,,fee schedule,,,14.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,14.16,,,fee schedule,,,14.16,,,fee schedule,,,10.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FUNGUS NOT SPECIFIED,3078110,CDM,302,RC,86671,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FUNGUS NOT SPECIFIED,3078110,CDM,302,RC,86671,CPT,,,,,,outpatient,facility,,,55,23.1,5.81,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,12.25,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,12.25,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.54,,,fee schedule,,,10.88,,,fee schedule,,,10.88,,,fee schedule,,,10.66,,,fee schedule,,,12.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,12.25,,,fee schedule,,,12.25,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB GIARDIA LAMBLIA,3078128,CDM,302,RC,86674,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB GIARDIA LAMBLIA,3078128,CDM,302,RC,86674,CPT,,,,,,outpatient,facility,,,67,28.14,12.81,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,14.72,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,15.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,14.72,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,21.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.87,,,fee schedule,,,13.07,,,fee schedule,,,13.07,,,fee schedule,,,12.81,,,fee schedule,,,14.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,14.72,,,fee schedule,,,14.72,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HELICOBACTER PYLORI,3078136,CDM,302,RC,86677,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HELICOBACTER PYLORI,3078136,CDM,302,RC,86677,CPT,,,,,,outpatient,facility,,,78,32.76,14.66,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,16.85,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,17.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,16.85,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,24.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.75,,,fee schedule,,,14.96,,,fee schedule,,,14.96,,,fee schedule,,,14.66,,,fee schedule,,,16.85,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,16.85,,,fee schedule,,,16.85,,,fee schedule,,,17.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HELMINTH NONSPECIFIED,3078144,CDM,302,RC,86682,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HELMINTH NONSPECIFIED,3078144,CDM,302,RC,86682,CPT,,,,,,outpatient,facility,,,65,27.3,11.32,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.01,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.01,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,18.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.56,,,fee schedule,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,11.32,,,fee schedule,,,13.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.01,,,fee schedule,,,13.01,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HAEMOPHILUS INFLUENZA IGG,3078169,CDM,302,RC,86684,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HAEMOPHILUS INFLUENZA IGG,3078169,CDM,302,RC,86684,CPT,,,,,,outpatient,facility,,,62,26.04,13.79,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,15.84,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,16.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,15.84,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,22.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.38,,,fee schedule,,,14.07,,,fee schedule,,,14.07,,,fee schedule,,,13.79,,,fee schedule,,,15.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,15.84,,,fee schedule,,,15.84,,,fee schedule,,,19.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS A IGM,3078185,CDM,302,RC,86709,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS A IGM,3078185,CDM,302,RC,86709,CPT,,,,,,outpatient,facility,,,55,23.1,9.8,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,11.26,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,11.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,11.26,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,16.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.2,,,fee schedule,,,10,,,fee schedule,,,10,,,fee schedule,,,9.8,,,fee schedule,,,11.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,11.26,,,fee schedule,,,11.26,,,fee schedule,,,10.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS B CORE IGM,3078201,CDM,302,RC,86705,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS B CORE IGM,3078201,CDM,302,RC,86705,CPT,,,,,,outpatient,facility,,,55,23.1,10.24,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,11.77,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,11.77,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.89,,,fee schedule,,,10.45,,,fee schedule,,,10.45,,,fee schedule,,,10.24,,,fee schedule,,,11.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,14.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS B CORE TOTAL,3078219,CDM,302,RC,86704,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS B CORE TOTAL,3078219,CDM,302,RC,86704,CPT,,,,,,outpatient,facility,,,55,23.1,10.49,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,12.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,10.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS B SURFACE,3078227,CDM,302,RC,86706,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS B SURFACE,3078227,CDM,302,RC,86706,CPT,,,,,,outpatient,facility,,,55,23.1,9.35,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,10.74,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,10.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,10.74,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,15.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.5,,,fee schedule,,,9.54,,,fee schedule,,,9.54,,,fee schedule,,,9.35,,,fee schedule,,,10.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,10.74,,,fee schedule,,,10.74,,,fee schedule,,,13.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS BE,3078235,CDM,302,RC,86707,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS BE,3078235,CDM,302,RC,86707,CPT,,,,,,outpatient,facility,,,59,24.78,10.06,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,11.57,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,11.57,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.62,,,fee schedule,,,10.27,,,fee schedule,,,10.27,,,fee schedule,,,10.06,,,fee schedule,,,11.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,11.57,,,fee schedule,,,11.57,,,fee schedule,,,14.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS C,3078243,CDM,302,RC,86803,CPT,,,,,,inpatient,facility,,,43,18.06,36.55,41.28,,36.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.41,,,percent of total billed charges,,,,,,,,,38.7,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS C,3078243,CDM,302,RC,86803,CPT,,,,,,outpatient,facility,,,43,18.06,11.61,41.28,,36.55,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,29.58,,,percent of total billed charges,,,28.94,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,14.27,,,fee schedule,,,37.41,,,percent of total billed charges,,,37.41,,,percent of total billed charges,,,36.55,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,14.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",38.7,,,percent of total billed charges,,,14.27,,,fee schedule,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,20.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.26,,,fee schedule,,,12.67,,,fee schedule,,,12.67,,,fee schedule,,,12.42,,,fee schedule,,,14.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",33.58,,,percent of total billed charges,,,39.13,,,percent of total billed charges,,,14.27,,,fee schedule,,,14.27,,,fee schedule,,,17.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS C CONFIRMATORY,3078250,CDM,302,RC,86804,CPT,,,,,,inpatient,facility,,,239,100.38,203.15,229.44,,203.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.93,,,percent of total billed charges,,,,,,,,,215.1,,,percent of total billed charges,,,229.44,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,222.27,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS C CONFIRMATORY,3078250,CDM,302,RC,86804,CPT,,,,,,outpatient,facility,,,239,100.38,13.48,229.44,,203.15,,,percent of total billed charges,,,64.53,,,percent of total billed charges,,,164.43,,,percent of total billed charges,,,160.85,,,percent of total billed charges,,,201.95,,,percent of total billed charges,,,15.49,,,fee schedule,,,207.93,,,percent of total billed charges,,,207.93,,,percent of total billed charges,,,203.15,,,percent of total billed charges,,,229.44,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",215.1,,,percent of total billed charges,,,15.49,,,fee schedule,,,222.27,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,22.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.91,,,fee schedule,,,13.76,,,fee schedule,,,13.76,,,fee schedule,,,13.48,,,fee schedule,,,15.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",186.66,,,percent of total billed charges,,,217.49,,,percent of total billed charges,,,15.49,,,fee schedule,,,15.49,,,fee schedule,,,18.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS DELTA AGENT,3078268,CDM,302,RC,86692,CPT,,,,,,inpatient,facility,,,85,35.7,72.25,81.6,,72.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,,,,,,,,76.5,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS DELTA AGENT,3078268,CDM,302,RC,86692,CPT,,,,,,outpatient,facility,,,85,35.7,14.94,81.6,,72.25,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,58.48,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,71.83,,,percent of total billed charges,,,17.16,,,fee schedule,,,73.95,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,72.25,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,17.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",76.5,,,percent of total billed charges,,,17.16,,,fee schedule,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,24.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.17,,,fee schedule,,,15.24,,,fee schedule,,,15.24,,,fee schedule,,,14.94,,,fee schedule,,,17.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",66.38,,,percent of total billed charges,,,77.35,,,percent of total billed charges,,,17.16,,,fee schedule,,,17.16,,,fee schedule,,,21.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HERPES SIMPLEX NONSPECIFIC,3078276,CDM,302,RC,86694,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HERPES SIMPLEX NONSPECIFIC,3078276,CDM,302,RC,86694,CPT,,,,,,outpatient,facility,,,44,18.48,11.88,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.39,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.39,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HERPES SIMPLEX TYPE 1,3078284,CDM,302,RC,86695,CPT,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HERPES SIMPLEX TYPE 1,3078284,CDM,302,RC,86695,CPT,,,,,,outpatient,facility,,,40,16.8,10.8,38.4,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,13.19,,,fee schedule,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36,,,percent of total billed charges,,,13.19,,,fee schedule,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HERPES SIMPLEX TYPE 2,3078292,CDM,302,RC,86696,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HERPES SIMPLEX TYPE 2,3078292,CDM,302,RC,86696,CPT,,,,,,outpatient,facility,,,59,24.78,15.93,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,19.35,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,19.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,19.35,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,28.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.12,,,fee schedule,,,17.18,,,fee schedule,,,17.18,,,fee schedule,,,16.84,,,fee schedule,,,19.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,19.35,,,fee schedule,,,19.35,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB HETEROPHILE,3078300,CDM,302,RC,86308,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB HETEROPHILE,3078300,CDM,302,RC,86308,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.18,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.18,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,4.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HISTOPLASMA IMMUNODIFFUSION,3078326,CDM,302,RC,86698,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HISTOPLASMA IMMUNODIFFUSION,3078326,CDM,302,RC,86698,CPT,,,,,,outpatient,facility,,,68,28.56,5.81,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,13.79,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,14.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,13.79,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,20,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.62,,,fee schedule,,,12.25,,,fee schedule,,,12.25,,,fee schedule,,,12.01,,,fee schedule,,,13.79,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,13.79,,,fee schedule,,,13.79,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HIV 1,3078334,CDM,302,RC,86701,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HIV 1,3078334,CDM,302,RC,86701,CPT,,,,,,outpatient,facility,,,76,31.92,7.73,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,8.89,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,9.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,8.89,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,12.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12,,,fee schedule,,,7.89,,,fee schedule,,,7.89,,,fee schedule,,,7.73,,,fee schedule,,,8.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,8.89,,,fee schedule,,,8.89,,,fee schedule,,,10.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HIV 1 ANDHIV 2 RESULT SGL,3078342,CDM,302,RC,86703,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HIV 1 ANDHIV 2 RESULT SGL,3078342,CDM,302,RC,86703,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.71,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,13.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.71,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,19.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.51,,,fee schedule,,,12.17,,,fee schedule,,,12.17,,,fee schedule,,,11.93,,,fee schedule,,,13.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.71,,,fee schedule,,,13.71,,,fee schedule,,,12.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HIV 2,3078359,CDM,302,RC,86702,CPT,,,,,,inpatient,facility,,,87,36.54,73.95,83.52,,73.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.69,,,percent of total billed charges,,,,,,,,,78.3,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,80.91,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HIV 2,3078359,CDM,302,RC,86702,CPT,,,,,,outpatient,facility,,,87,36.54,11.77,83.52,,73.95,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,59.86,,,percent of total billed charges,,,58.55,,,percent of total billed charges,,,73.52,,,percent of total billed charges,,,13.52,,,fee schedule,,,75.69,,,percent of total billed charges,,,75.69,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,13.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",78.3,,,percent of total billed charges,,,13.52,,,fee schedule,,,80.91,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,19.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.25,,,fee schedule,,,12.01,,,fee schedule,,,12.01,,,fee schedule,,,11.77,,,fee schedule,,,13.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",67.95,,,percent of total billed charges,,,79.17,,,percent of total billed charges,,,13.52,,,fee schedule,,,13.52,,,fee schedule,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE HLA B 27 AG SINGLE,3078375,CDM,302,RC,86812,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE HLA B 27 AG SINGLE,3078375,CDM,302,RC,86812,CPT,,,,,,outpatient,facility,,,78,32.76,21.06,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,25.81,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,26.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,25.81,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,37.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.84,,,fee schedule,,,22.92,,,fee schedule,,,22.92,,,fee schedule,,,22.46,,,fee schedule,,,25.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,25.81,,,fee schedule,,,25.81,,,fee schedule,,,28.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HTLV I,3078425,CDM,302,RC,86687,CPT,,,,,,inpatient,facility,,,28,11.76,23.8,26.88,,23.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.36,,,percent of total billed charges,,,,,,,,,25.2,,,percent of total billed charges,,,26.88,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.04,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HTLV I,3078425,CDM,302,RC,86687,CPT,,,,,,outpatient,facility,,,28,11.76,7.56,26.88,,23.8,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,19.26,,,percent of total billed charges,,,18.84,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,9.09,,,fee schedule,,,24.36,,,percent of total billed charges,,,24.36,,,percent of total billed charges,,,23.8,,,percent of total billed charges,,,26.88,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,9.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.2,,,percent of total billed charges,,,9.09,,,fee schedule,,,26.04,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,13.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.27,,,fee schedule,,,8.07,,,fee schedule,,,8.07,,,fee schedule,,,7.91,,,fee schedule,,,9.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",21.87,,,percent of total billed charges,,,25.48,,,percent of total billed charges,,,9.09,,,fee schedule,,,9.09,,,fee schedule,,,10.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMMUNE COMPLEX C1Q BINDING,3078466,CDM,302,RC,86332,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMMUNE COMPLEX C1Q BINDING,3078466,CDM,302,RC,86332,CPT,,,,,,outpatient,facility,,,74,31.08,19.98,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,24.37,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,24.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,24.37,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,35.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.9,,,fee schedule,,,21.64,,,fee schedule,,,21.64,,,fee schedule,,,21.21,,,fee schedule,,,24.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,24.37,,,fee schedule,,,24.37,,,fee schedule,,,29.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AG TUMOR CA 125,3078508,CDM,302,RC,86304,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AG TUMOR CA 125,3078508,CDM,302,RC,86304,CPT,,,,,,outpatient,facility,,,63,26.46,17.01,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,20.81,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,20.81,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,30.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.09,,,fee schedule,,,18.48,,,fee schedule,,,18.48,,,fee schedule,,,18.11,,,fee schedule,,,20.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,20.81,,,fee schedule,,,20.81,,,fee schedule,,,25.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AG TUMOR CA 15 3,3078516,CDM,302,RC,86300,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AG TUMOR CA 15 3,3078516,CDM,302,RC,86300,CPT,,,,,,outpatient,facility,,,63,26.46,17.01,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,20.81,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,20.81,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,30.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.09,,,fee schedule,,,18.48,,,fee schedule,,,18.48,,,fee schedule,,,18.11,,,fee schedule,,,20.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,20.81,,,fee schedule,,,20.81,,,fee schedule,,,25.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AG TUMOR CA 19 9,3078524,CDM,302,RC,86301,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AG TUMOR CA 19 9,3078524,CDM,302,RC,86301,CPT,,,,,,outpatient,facility,,,63,26.46,17.01,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,20.81,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,20.81,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,30.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.09,,,fee schedule,,,18.48,,,fee schedule,,,18.48,,,fee schedule,,,18.11,,,fee schedule,,,20.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,20.81,,,fee schedule,,,20.81,,,fee schedule,,,25.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AG TUMOR CA 27 29,3078532,CDM,302,RC,86300,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AG TUMOR CA 27 29,3078532,CDM,302,RC,86300,CPT,,,,,,outpatient,facility,,,63,26.46,17.01,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,20.81,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,20.81,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,30.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.09,,,fee schedule,,,18.48,,,fee schedule,,,18.48,,,fee schedule,,,18.11,,,fee schedule,,,20.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,20.81,,,fee schedule,,,20.81,,,fee schedule,,,25.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AG TUMOR OTHER QN NS,3078540,CDM,302,RC,86316,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AG TUMOR OTHER QN NS,3078540,CDM,302,RC,86316,CPT,,,,,,outpatient,facility,,,75,31.5,18.11,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,20.81,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,21.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,20.81,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,30.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.09,,,fee schedule,,,18.48,,,fee schedule,,,18.48,,,fee schedule,,,18.11,,,fee schedule,,,20.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,20.81,,,fee schedule,,,20.81,,,fee schedule,,,25.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMDF,3078565,CDM,302,RC,86329,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMDF,3078565,CDM,302,RC,86329,CPT,,,,,,outpatient,facility,,,55,23.1,9.24,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,14.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,14.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,14.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,20.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.97,,,fee schedule,,,12.48,,,fee schedule,,,12.48,,,fee schedule,,,12.23,,,fee schedule,,,14.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,14.05,,,fee schedule,,,14.05,,,fee schedule,,,9.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMDF GEL AB AG QL,3078573,CDM,302,RC,86331,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMDF GEL AB AG QL,3078573,CDM,302,RC,86331,CPT,,,,,,outpatient,facility,,,56,23.52,10.43,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,11.98,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMMUNOELECTROPHORESIS SERUM,3078599,CDM,302,RC,86320,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMMUNOELECTROPHORESIS SERUM,3078599,CDM,302,RC,86320,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,29.92,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,30.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,29.92,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,43.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",40.39,,,fee schedule,,,26.57,,,fee schedule,,,26.57,,,fee schedule,,,26.04,,,fee schedule,,,29.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,29.92,,,fee schedule,,,29.92,,,fee schedule,,,27.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMMUNOFIXATION EP URINE CSF,3078615,CDM,302,RC,86335,CPT,,,,,,inpatient,facility,,,89,37.38,75.65,85.44,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,,,,,,,80.1,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMMUNOFIXATION EP URINE CSF,3078615,CDM,302,RC,86335,CPT,,,,,,outpatient,facility,,,89,37.38,24.03,85.44,,75.65,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,61.23,,,percent of total billed charges,,,59.9,,,percent of total billed charges,,,75.2,,,percent of total billed charges,,,29.35,,,fee schedule,,,77.43,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,75.65,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,29.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",80.1,,,percent of total billed charges,,,29.35,,,fee schedule,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,42.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.62,,,fee schedule,,,26.06,,,fee schedule,,,26.06,,,fee schedule,,,25.54,,,fee schedule,,,29.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",69.51,,,percent of total billed charges,,,80.99,,,percent of total billed charges,,,29.35,,,fee schedule,,,29.35,,,fee schedule,,,35.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB INFLUENZA A,3078631,CDM,302,RC,86710,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB INFLUENZA A,3078631,CDM,302,RC,86710,CPT,,,,,,outpatient,facility,,,68,28.56,11.79,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,13.55,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,13.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,13.55,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,19.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.29,,,fee schedule,,,12.03,,,fee schedule,,,12.03,,,fee schedule,,,11.79,,,fee schedule,,,13.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,13.55,,,fee schedule,,,13.55,,,fee schedule,,,16.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB INFLUENZA B,3078656,CDM,302,RC,86710,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB INFLUENZA B,3078656,CDM,302,RC,86710,CPT,,,,,,outpatient,facility,,,68,28.56,11.79,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,13.55,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,13.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,13.55,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,19.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.29,,,fee schedule,,,12.03,,,fee schedule,,,12.03,,,fee schedule,,,11.79,,,fee schedule,,,13.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,13.55,,,fee schedule,,,13.55,,,fee schedule,,,16.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INHIBIN A NS,3078664,CDM,302,RC,86336,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INHIBIN A NS,3078664,CDM,302,RC,86336,CPT,,,,,,outpatient,facility,,,77,32.34,13.56,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,15.59,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,15.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,15.59,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,22.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.05,,,fee schedule,,,13.84,,,fee schedule,,,13.84,,,fee schedule,,,13.56,,,fee schedule,,,15.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,15.59,,,fee schedule,,,15.59,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB INSULIN,3078672,CDM,302,RC,86337,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB INSULIN,3078672,CDM,302,RC,86337,CPT,,,,,,outpatient,facility,,,66,27.72,17.82,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,21.41,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,21.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,21.41,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,31.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.9,,,fee schedule,,,19.01,,,fee schedule,,,19.01,,,fee schedule,,,18.63,,,fee schedule,,,21.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,21.41,,,fee schedule,,,21.41,,,fee schedule,,,26.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB INTRINSIC FACTOR,3078680,CDM,302,RC,86340,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB INTRINSIC FACTOR,3078680,CDM,302,RC,86340,CPT,,,,,,outpatient,facility,,,59,24.78,13.12,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,15.08,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,15.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,15.08,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,21.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.36,,,fee schedule,,,13.39,,,fee schedule,,,13.39,,,fee schedule,,,13.12,,,fee schedule,,,15.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,15.08,,,fee schedule,,,15.08,,,fee schedule,,,18.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ISLET CELL NS,3078698,CDM,302,RC,86341,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ISLET CELL NS,3078698,CDM,302,RC,86341,CPT,,,,,,outpatient,facility,,,71,29.82,19.17,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,23.57,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,24.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,23.57,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,34.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.82,,,fee schedule,,,20.93,,,fee schedule,,,20.93,,,fee schedule,,,20.51,,,fee schedule,,,23.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,23.57,,,fee schedule,,,23.57,,,fee schedule,,,24.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB LEGIONELLA,3078714,CDM,302,RC,86713,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB LEGIONELLA,3078714,CDM,302,RC,86713,CPT,,,,,,outpatient,facility,,,72,30.24,13.32,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,15.3,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,15.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,15.3,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,22.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.66,,,fee schedule,,,13.59,,,fee schedule,,,13.59,,,fee schedule,,,13.32,,,fee schedule,,,15.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,15.3,,,fee schedule,,,15.3,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB LEISHMANIA,3078722,CDM,302,RC,86717,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB LEISHMANIA,3078722,CDM,302,RC,86717,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.25,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.25,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.54,,,fee schedule,,,10.88,,,fee schedule,,,10.88,,,fee schedule,,,10.66,,,fee schedule,,,12.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.25,,,fee schedule,,,12.25,,,fee schedule,,,15.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ID LEUKOCYTE,3078748,CDM,302,RC,86021,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ID LEUKOCYTE,3078748,CDM,302,RC,86021,CPT,,,,,,outpatient,facility,,,55,23.1,13.09,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,15.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,15.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,15.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.32,,,fee schedule,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,13.09,,,fee schedule,,,15.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,15.05,,,fee schedule,,,15.05,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ID LEUKOCYTE NS,3078755,CDM,302,RC,86021,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ID LEUKOCYTE NS,3078755,CDM,302,RC,86021,CPT,,,,,,outpatient,facility,,,54,22.68,13.09,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,15.05,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,15.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,15.05,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.32,,,fee schedule,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,13.09,,,fee schedule,,,15.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,15.05,,,fee schedule,,,15.05,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRANSFORM LYMPHOCYTE MITOGEN,3078813,CDM,302,RC,86353,CPT,,,,,,inpatient,facility,,,148,62.16,125.8,142.08,,125.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.76,,,percent of total billed charges,,,,,,,,,133.2,,,percent of total billed charges,,,142.08,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.64,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFORM LYMPHOCYTE MITOGEN,3078813,CDM,302,RC,86353,CPT,,,,,,outpatient,facility,,,148,62.16,39.96,142.08,,125.8,,,percent of total billed charges,,,39.96,,,percent of total billed charges,,,101.82,,,percent of total billed charges,,,99.6,,,percent of total billed charges,,,125.06,,,percent of total billed charges,,,49.03,,,fee schedule,,,128.76,,,percent of total billed charges,,,128.76,,,percent of total billed charges,,,125.8,,,percent of total billed charges,,,142.08,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,50.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",133.2,,,percent of total billed charges,,,49.03,,,fee schedule,,,137.64,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,71.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.19,,,fee schedule,,,43.54,,,fee schedule,,,43.54,,,fee schedule,,,42.67,,,fee schedule,,,49.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",115.59,,,percent of total billed charges,,,134.68,,,percent of total billed charges,,,49.03,,,fee schedule,,,49.03,,,fee schedule,,,60.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHORIOMENINGITIS LYMPHOCYTIC,3078839,CDM,302,RC,86727,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHORIOMENINGITIS LYMPHOCYTIC,3078839,CDM,302,RC,86727,CPT,,,,,,outpatient,facility,,,62,26.04,5.81,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,12.87,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,13.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,12.87,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,18.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.37,,,fee schedule,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,11.2,,,fee schedule,,,12.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,12.87,,,fee schedule,,,12.87,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB MICROSOMAL EA,3078854,CDM,302,RC,86376,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB MICROSOMAL EA,3078854,CDM,302,RC,86376,CPT,,,,,,outpatient,facility,,,44,18.48,11.88,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.55,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.55,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,21.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.64,,,fee schedule,,,12.92,,,fee schedule,,,12.92,,,fee schedule,,,12.66,,,fee schedule,,,14.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.55,,,fee schedule,,,14.55,,,fee schedule,,,13.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB MICROSOMAL LIVER KIDNEY EA,3078862,CDM,302,RC,86376,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB MICROSOMAL LIVER KIDNEY EA,3078862,CDM,302,RC,86376,CPT,,,,,,outpatient,facility,,,63,26.46,12.66,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,14.55,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,14.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,14.55,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.64,,,fee schedule,,,12.92,,,fee schedule,,,12.92,,,fee schedule,,,12.66,,,fee schedule,,,14.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,14.55,,,fee schedule,,,14.55,,,fee schedule,,,13.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB MUMPS,3078888,CDM,302,RC,86735,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB MUMPS,3078888,CDM,302,RC,86735,CPT,,,,,,outpatient,facility,,,61,25.62,11.36,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,13.05,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,13.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,13.05,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,18.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.62,,,fee schedule,,,11.59,,,fee schedule,,,11.59,,,fee schedule,,,11.36,,,fee schedule,,,13.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,13.05,,,fee schedule,,,13.05,,,fee schedule,,,16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB MUMPS IGG,3078896,CDM,302,RC,86735,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB MUMPS IGG,3078896,CDM,302,RC,86735,CPT,,,,,,outpatient,facility,,,56,23.52,11.36,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,13.05,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,13.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,13.05,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.62,,,fee schedule,,,11.59,,,fee schedule,,,11.59,,,fee schedule,,,11.36,,,fee schedule,,,13.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,13.05,,,fee schedule,,,13.05,,,fee schedule,,,16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB MUMPS IGM,3078904,CDM,302,RC,86735,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB MUMPS IGM,3078904,CDM,302,RC,86735,CPT,,,,,,outpatient,facility,,,62,26.04,11.36,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,13.05,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,13.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,13.05,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,18.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.62,,,fee schedule,,,11.59,,,fee schedule,,,11.59,,,fee schedule,,,11.36,,,fee schedule,,,13.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,13.05,,,fee schedule,,,13.05,,,fee schedule,,,16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB MYCOPLASMA IGM,3078938,CDM,302,RC,86738,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB MYCOPLASMA IGM,3078938,CDM,302,RC,86738,CPT,,,,,,outpatient,facility,,,55,23.1,11.52,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,13.24,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,13.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,13.24,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,19.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.87,,,fee schedule,,,11.76,,,fee schedule,,,11.76,,,fee schedule,,,11.52,,,fee schedule,,,13.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,13.24,,,fee schedule,,,13.24,,,fee schedule,,,16.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NEUTRALIZATION VIRAL,3078953,CDM,302,RC,86382,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NEUTRALIZATION VIRAL,3078953,CDM,302,RC,86382,CPT,,,,,,outpatient,facility,,,69,28.98,14.72,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,16.91,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,17.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,16.91,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,24.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.83,,,fee schedule,,,15.02,,,fee schedule,,,15.02,,,fee schedule,,,14.72,,,fee schedule,,,16.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,16.91,,,fee schedule,,,16.91,,,fee schedule,,,20.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB CRYPTO AGG PARTICLE,3078995,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB CRYPTO AGG PARTICLE,3078995,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,59,24.78,10.05,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,11.54,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,11.54,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB NEISS AGG PARTICLE,3079019,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB NEISS AGG PARTICLE,3079019,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,74,31.08,10.05,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,11.54,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,11.54,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB NEISS GRP A AGG PARTICLE,3079027,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB NEISS GRP A AGG PARTICLE,3079027,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,53,22.26,10.05,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,11.54,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,11.54,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB NEISS GRP C AGG PARTICLE,3079043,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB NEISS GRP C AGG PARTICLE,3079043,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,53,22.26,10.05,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,11.54,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,11.54,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB STREP PNEUMO AGGPARTICLE,3079050,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB STREP PNEUMO AGGPARTICLE,3079050,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,53,22.26,10.05,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,11.54,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,11.54,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AGG PARTICLE TITER,3079076,CDM,302,RC,86406,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AGG PARTICLE TITER,3079076,CDM,302,RC,86406,CPT,,,,,,outpatient,facility,,,59,24.78,9.26,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,10.64,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,10.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,10.64,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,15.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.36,,,fee schedule,,,9.45,,,fee schedule,,,9.45,,,fee schedule,,,9.26,,,fee schedule,,,10.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,13.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB PARVOVIRUS B19 IGG,3079092,CDM,302,RC,86747,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB PARVOVIRUS B19 IGG,3079092,CDM,302,RC,86747,CPT,,,,,,outpatient,facility,,,62,26.04,13.08,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,15.03,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,15.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,15.03,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,21.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.29,,,fee schedule,,,13.35,,,fee schedule,,,13.35,,,fee schedule,,,13.08,,,fee schedule,,,15.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,15.03,,,fee schedule,,,15.03,,,fee schedule,,,18.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB PARVOVIRUS B19 IGM,3079100,CDM,302,RC,86747,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB PARVOVIRUS B19 IGM,3079100,CDM,302,RC,86747,CPT,,,,,,outpatient,facility,,,62,26.04,13.08,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,15.03,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,15.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,15.03,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,21.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.29,,,fee schedule,,,13.35,,,fee schedule,,,13.35,,,fee schedule,,,13.08,,,fee schedule,,,15.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,15.03,,,fee schedule,,,15.03,,,fee schedule,,,18.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ANTIPHOSPHATIDYLSERINE,3079118,CDM,302,RC,86148,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ANTIPHOSPHATIDYLSERINE,3079118,CDM,302,RC,86148,CPT,,,,,,outpatient,facility,,,57,23.94,13.98,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,16.07,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,16.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,16.07,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,23.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.69,,,fee schedule,,,14.27,,,fee schedule,,,14.27,,,fee schedule,,,13.98,,,fee schedule,,,16.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,16.07,,,fee schedule,,,16.07,,,fee schedule,,,19.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ID PLATELET PATIENT SERUM,3079134,CDM,302,RC,86022,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ID PLATELET PATIENT SERUM,3079134,CDM,302,RC,86022,CPT,,,,,,outpatient,facility,,,56,23.52,15.12,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,18.37,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,18.37,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,26.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.8,,,fee schedule,,,16.31,,,fee schedule,,,16.31,,,fee schedule,,,15.98,,,fee schedule,,,18.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,18.37,,,fee schedule,,,18.37,,,fee schedule,,,22.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR ALLG IGE QL MULTI,3079175,CDM,302,RC,86005,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR ALLG IGE QL MULTI,3079175,CDM,302,RC,86005,CPT,,,,,,outpatient,facility,,,56,23.52,6.94,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,7.97,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,8.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,7.97,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,11.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.76,,,fee schedule,,,7.08,,,fee schedule,,,7.08,,,fee schedule,,,6.94,,,fee schedule,,,7.97,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,7.97,,,fee schedule,,,7.97,,,fee schedule,,,8.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ELUTION AB RBC EA,3079183,CDM,302,RC,86860,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ELUTION AB RBC EA,3079183,CDM,302,RC,86860,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ELUTION AB RBC EA,3079183,CDM,302,RC,86860,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FACTOR RHEUMATOID QL,3079209,CDM,302,RC,86430,CPT,,,,,,inpatient,facility,,,70,29.4,59.5,67.2,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.9,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FACTOR RHEUMATOID QL,3079209,CDM,302,RC,86430,CPT,,,,,,outpatient,facility,,,70,29.4,4.6,67.2,,59.5,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,47.11,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,6.14,,,fee schedule,,,60.9,,,percent of total billed charges,,,60.9,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,6.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63,,,percent of total billed charges,,,6.14,,,fee schedule,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,8.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.29,,,fee schedule,,,5.45,,,fee schedule,,,5.45,,,fee schedule,,,5.34,,,fee schedule,,,6.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",54.67,,,percent of total billed charges,,,63.7,,,percent of total billed charges,,,6.14,,,fee schedule,,,6.14,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FACTOR RHEUMATOID QN,3079217,CDM,302,RC,86431,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FACTOR RHEUMATOID QN,3079217,CDM,302,RC,86431,CPT,,,,,,outpatient,facility,,,18,7.56,4.6,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.67,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.67,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.65,,,fee schedule,,,5.03,,,fee schedule,,,5.03,,,fee schedule,,,4.93,,,fee schedule,,,5.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.67,,,fee schedule,,,5.67,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB RICKETTSIA,3079225,CDM,302,RC,86757,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB RICKETTSIA,3079225,CDM,302,RC,86757,CPT,,,,,,outpatient,facility,,,71,29.82,16.84,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,19.35,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,19.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,19.35,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,28.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.12,,,fee schedule,,,17.18,,,fee schedule,,,17.18,,,fee schedule,,,16.84,,,fee schedule,,,19.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,19.35,,,fee schedule,,,19.35,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB RSV,3079258,CDM,302,RC,86756,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB RSV,3079258,CDM,302,RC,86756,CPT,,,,,,outpatient,facility,,,72,30.24,13.83,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,15.89,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,16.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,15.89,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,23.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.45,,,fee schedule,,,14.11,,,fee schedule,,,14.11,,,fee schedule,,,13.83,,,fee schedule,,,15.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,15.89,,,fee schedule,,,15.89,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB RUBELLA IGG,3079274,CDM,302,RC,86762,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB RUBELLA IGG,3079274,CDM,302,RC,86762,CPT,,,,,,outpatient,facility,,,56,23.52,12.52,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,14.39,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,14.39,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB RUBELLA IGM NS,3079282,CDM,302,RC,86762,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB RUBELLA IGM NS,3079282,CDM,302,RC,86762,CPT,,,,,,outpatient,facility,,,56,23.52,12.52,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,14.39,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,14.39,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB RUBEOLA IGG,3079308,CDM,302,RC,86765,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB RUBEOLA IGG,3079308,CDM,302,RC,86765,CPT,,,,,,outpatient,facility,,,60,25.2,11.21,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,12.88,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB RUBEOLA IGM,3079316,CDM,302,RC,86765,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB RUBEOLA IGM,3079316,CDM,302,RC,86765,CPT,,,,,,outpatient,facility,,,56,23.52,11.21,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,12.88,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,12.88,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB SALMONELLA,3079340,CDM,302,RC,86768,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB SALMONELLA,3079340,CDM,302,RC,86768,CPT,,,,,,outpatient,facility,,,73,30.66,11.48,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,13.19,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,13.19,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SYPHILIS VDRL RPR QL,3079373,CDM,302,RC,86592,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SYPHILIS VDRL RPR QL,3079373,CDM,302,RC,86592,CPT,,,,,,outpatient,facility,,,52,21.84,3.62,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,4.27,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,4.27,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,3.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SYPHILIS VDRL RPR QL CSF,3079381,CDM,302,RC,86592,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SYPHILIS VDRL RPR QL CSF,3079381,CDM,302,RC,86592,CPT,,,,,,outpatient,facility,,,62,26.04,3.62,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,4.27,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,4.27,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,3.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SYPHILIS VDRL RPR QN,3079399,CDM,302,RC,86593,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SYPHILIS VDRL RPR QN,3079399,CDM,302,RC,86593,CPT,,,,,,outpatient,facility,,,52,21.84,3.83,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,4.4,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,4.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,4.4,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,6.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.94,,,fee schedule,,,3.91,,,fee schedule,,,3.91,,,fee schedule,,,3.83,,,fee schedule,,,4.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,4.4,,,fee schedule,,,4.4,,,fee schedule,,,5.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT CELLS T CD4 ANDCD8 RATIO,3079407,CDM,302,RC,86360,CPT,,,,,,inpatient,facility,,,141,59.22,119.85,135.36,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELLS T CD4 ANDCD8 RATIO,3079407,CDM,302,RC,86360,CPT,,,,,,outpatient,facility,,,141,59.22,38.07,135.36,,119.85,,,percent of total billed charges,,,38.07,,,percent of total billed charges,,,97.01,,,percent of total billed charges,,,94.89,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,46.98,,,fee schedule,,,122.67,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,47.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",126.9,,,percent of total billed charges,,,46.98,,,fee schedule,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,68.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.42,,,fee schedule,,,41.72,,,fee schedule,,,41.72,,,fee schedule,,,40.89,,,fee schedule,,,46.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",110.12,,,percent of total billed charges,,,128.31,,,percent of total billed charges,,,46.98,,,fee schedule,,,46.98,,,fee schedule,,,57.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT TOTAL CELLS T,3079415,CDM,302,RC,86359,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT TOTAL CELLS T,3079415,CDM,302,RC,86359,CPT,,,,,,outpatient,facility,,,114,47.88,30.78,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,37.73,,,fee schedule,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.6,,,percent of total billed charges,,,37.73,,,fee schedule,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,46.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB TETANUS,3079431,CDM,302,RC,86774,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB TETANUS,3079431,CDM,302,RC,86774,CPT,,,,,,outpatient,facility,,,63,26.46,12.88,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,14.8,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,15.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,14.8,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,21.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.98,,,fee schedule,,,13.14,,,fee schedule,,,13.14,,,fee schedule,,,12.88,,,fee schedule,,,14.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,14.8,,,fee schedule,,,14.8,,,fee schedule,,,18.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB THYROGLOBULIN,3079449,CDM,302,RC,86800,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB THYROGLOBULIN,3079449,CDM,302,RC,86800,CPT,,,,,,outpatient,facility,,,57,23.94,13.85,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,15.91,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,16.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,15.91,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,23.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.48,,,fee schedule,,,14.13,,,fee schedule,,,14.13,,,fee schedule,,,13.85,,,fee schedule,,,15.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,15.91,,,fee schedule,,,15.91,,,fee schedule,,,19.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB TOXOPLASMA IGG NS,3079464,CDM,302,RC,86777,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB TOXOPLASMA IGG NS,3079464,CDM,302,RC,86777,CPT,,,,,,outpatient,facility,,,63,26.46,12.52,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,14.39,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,14.39,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB TOXOPLASMA IGM NS,3079472,CDM,302,RC,86778,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB TOXOPLASMA IGM NS,3079472,CDM,302,RC,86778,CPT,,,,,,outpatient,facility,,,44,18.48,11.88,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.41,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.41,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,20.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.45,,,fee schedule,,,12.8,,,fee schedule,,,12.8,,,fee schedule,,,12.54,,,fee schedule,,,14.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.41,,,fee schedule,,,14.41,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB VARICELLA ZOSTER IGG,3079514,CDM,302,RC,86787,CPT,,,,,,inpatient,facility,,,39,16.38,33.15,37.44,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.93,,,percent of total billed charges,,,,,,,,,35.1,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB VARICELLA ZOSTER IGG,3079514,CDM,302,RC,86787,CPT,,,,,,outpatient,facility,,,39,16.38,10.53,37.44,,33.15,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,32.95,,,percent of total billed charges,,,12.88,,,fee schedule,,,33.93,,,percent of total billed charges,,,33.93,,,percent of total billed charges,,,33.15,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.1,,,percent of total billed charges,,,12.88,,,fee schedule,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",30.46,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB VARICELLA ZOSTER IGM,3079522,CDM,302,RC,86787,CPT,,,,,,inpatient,facility,,,39,16.38,33.15,37.44,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.93,,,percent of total billed charges,,,,,,,,,35.1,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB VARICELLA ZOSTER IGM,3079522,CDM,302,RC,86787,CPT,,,,,,outpatient,facility,,,39,16.38,10.53,37.44,,33.15,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,32.95,,,percent of total billed charges,,,12.88,,,fee schedule,,,33.93,,,percent of total billed charges,,,33.93,,,percent of total billed charges,,,33.15,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.1,,,percent of total billed charges,,,12.88,,,fee schedule,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",30.46,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB VIRUS NONSPECIFIED,3079530,CDM,302,RC,86790,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB VIRUS NONSPECIFIED,3079530,CDM,302,RC,86790,CPT,,,,,,outpatient,facility,,,65,27.3,11.21,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,12.88,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,12.88,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT C ACT RESISTANCE,3079548,CDM,305,RC,85307,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT C ACT RESISTANCE,3079548,CDM,305,RC,85307,CPT,,,,,,outpatient,facility,,,66,27.72,13.33,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,15.32,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,15.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,15.32,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,22.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.68,,,fee schedule,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.33,,,fee schedule,,,15.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,15.32,,,fee schedule,,,15.32,,,fee schedule,,,14.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANTIPLASMIN ALPHA 2,3079555,CDM,305,RC,85410,CPT,,,,,,inpatient,facility,,,24,10.08,20.4,23.04,,20.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,21.6,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANTIPLASMIN ALPHA 2,3079555,CDM,305,RC,85410,CPT,,,,,,outpatient,facility,,,24,10.08,6.48,23.04,,20.4,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,16.51,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,20.28,,,percent of total billed charges,,,7.71,,,fee schedule,,,20.88,,,percent of total billed charges,,,20.88,,,percent of total billed charges,,,20.4,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,7.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.6,,,percent of total billed charges,,,7.71,,,fee schedule,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,11.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.41,,,fee schedule,,,6.85,,,fee schedule,,,6.85,,,fee schedule,,,6.71,,,fee schedule,,,7.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",18.74,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,7.71,,,fee schedule,,,7.71,,,fee schedule,,,9.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING ACT ANTITHROM 3,3079563,CDM,305,RC,85300,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING ACT ANTITHROM 3,3079563,CDM,305,RC,85300,CPT,,,,,,outpatient,facility,,,63,26.46,10.31,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,11.85,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,12.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,11.85,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,17.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16,,,fee schedule,,,10.52,,,fee schedule,,,10.52,,,fee schedule,,,10.31,,,fee schedule,,,11.85,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,11.85,,,fee schedule,,,11.85,,,fee schedule,,,14.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD LEUKO AUTO,3079589,CDM,305,RC,85048,CPT,,,,,,inpatient,facility,,,8,3.36,6.8,7.68,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD LEUKO AUTO,3079589,CDM,305,RC,85048,CPT,,,,,,outpatient,facility,,,8,3.36,1.95,7.68,,6.8,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,2.54,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.2,,,percent of total billed charges,,,2.54,,,fee schedule,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,3.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.43,,,fee schedule,,,2.26,,,fee schedule,,,2.26,,,fee schedule,,,2.21,,,fee schedule,,,2.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,2.54,,,fee schedule,,,2.54,,,fee schedule,,,1.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD PLATELET AUTOMATED,3079605,CDM,305,RC,85049,CPT,,,,,,inpatient,facility,,,14,5.88,11.9,13.44,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD PLATELET AUTOMATED,3079605,CDM,305,RC,85049,CPT,,,,,,outpatient,facility,,,14,5.88,3.78,13.44,,11.9,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.48,,,fee schedule,,,12.18,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,11.9,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,4.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.6,,,percent of total billed charges,,,4.48,,,fee schedule,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,6.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.05,,,fee schedule,,,3.98,,,fee schedule,,,3.98,,,fee schedule,,,3.9,,,fee schedule,,,4.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.93,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,4.48,,,fee schedule,,,4.48,,,fee schedule,,,4.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD RBC AUTO,3079613,CDM,305,RC,85041,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD RBC AUTO,3079613,CDM,305,RC,85041,CPT,,,,,,outpatient,facility,,,62,26.04,2.12,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,3.02,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,3.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,3.02,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,4.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.08,,,fee schedule,,,2.68,,,fee schedule,,,2.68,,,fee schedule,,,2.63,,,fee schedule,,,3.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,3.02,,,fee schedule,,,3.02,,,fee schedule,,,2.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD RETIC MANUAL,3079639,CDM,305,RC,85044,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD RETIC MANUAL,3079639,CDM,305,RC,85044,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.31,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.31,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.82,,,fee schedule,,,3.83,,,fee schedule,,,3.83,,,fee schedule,,,3.75,,,fee schedule,,,4.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.31,,,fee schedule,,,4.31,,,fee schedule,,,4.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD DIFF MANUAL WBC,3079654,CDM,305,RC,85007,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD DIFF MANUAL WBC,3079654,CDM,305,RC,85007,CPT,,,,,,outpatient,facility,,,54,22.68,2.52,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,3.8,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,3.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,3.8,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,5.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.13,,,fee schedule,,,3.37,,,fee schedule,,,3.37,,,fee schedule,,,3.3,,,fee schedule,,,3.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,3.8,,,fee schedule,,,3.8,,,fee schedule,,,2.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CBC AUTO W AUTO DIFF,3079688,CDM,305,RC,85025,CPT,,,,,,inpatient,facility,,,24,10.08,20.4,23.04,,20.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,21.6,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CBC AUTO W AUTO DIFF,3079688,CDM,305,RC,85025,CPT,,,,,,outpatient,facility,,,24,10.08,6.48,23.04,,20.4,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,16.51,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,20.28,,,percent of total billed charges,,,7.77,,,fee schedule,,,20.88,,,percent of total billed charges,,,20.88,,,percent of total billed charges,,,20.4,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,7.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.6,,,percent of total billed charges,,,7.77,,,fee schedule,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,11.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.49,,,fee schedule,,,6.9,,,fee schedule,,,6.9,,,fee schedule,,,6.76,,,fee schedule,,,7.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",18.74,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,7.77,,,fee schedule,,,7.77,,,fee schedule,,,9.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CBC AUTO WO DIFF,3079696,CDM,305,RC,85027,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CBC AUTO WO DIFF,3079696,CDM,305,RC,85027,CPT,,,,,,outpatient,facility,,,20,8.4,5.4,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.47,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.47,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,7.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 2 PROTHROM,3079720,CDM,305,RC,85210,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 2 PROTHROM,3079720,CDM,305,RC,85210,CPT,,,,,,outpatient,facility,,,64,26.88,11.3,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,12.98,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,13.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,12.98,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,18.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.52,,,fee schedule,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,11.3,,,fee schedule,,,12.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,12.98,,,fee schedule,,,12.98,,,fee schedule,,,15.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LYSIS EUGLOBULIN,3079738,CDM,305,RC,85360,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LYSIS EUGLOBULIN,3079738,CDM,305,RC,85360,CPT,,,,,,outpatient,facility,,,26,10.92,7.02,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.41,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.41,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.35,,,fee schedule,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.32,,,fee schedule,,,8.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.41,,,fee schedule,,,8.41,,,fee schedule,,,10.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 8 1 STG,3079746,CDM,305,RC,85240,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 8 1 STG,3079746,CDM,305,RC,85240,CPT,,,,,,outpatient,facility,,,66,27.72,14.02,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,17.9,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,18.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,17.9,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,25.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.16,,,fee schedule,,,15.9,,,fee schedule,,,15.9,,,fee schedule,,,15.58,,,fee schedule,,,17.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,17.9,,,fee schedule,,,17.9,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INHIBITOR FACTOR 9,3079761,CDM,305,RC,85335,CPT,,,,,,inpatient,facility,,,39,16.38,33.15,37.44,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.93,,,percent of total billed charges,,,,,,,,,35.1,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INHIBITOR FACTOR 9,3079761,CDM,305,RC,85335,CPT,,,,,,outpatient,facility,,,39,16.38,10.53,37.44,,33.15,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,32.95,,,percent of total billed charges,,,12.87,,,fee schedule,,,33.93,,,percent of total billed charges,,,33.93,,,percent of total billed charges,,,33.15,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,13.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.1,,,percent of total billed charges,,,12.87,,,fee schedule,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,18.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.37,,,fee schedule,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,11.2,,,fee schedule,,,12.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",30.46,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,12.87,,,fee schedule,,,12.87,,,fee schedule,,,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INHIBITOR FACTOR 8,3079779,CDM,305,RC,85335,CPT,,,,,,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INHIBITOR FACTOR 8,3079779,CDM,305,RC,85335,CPT,,,,,,outpatient,facility,,,97,40.74,11.2,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,12.87,,,fee schedule,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,13.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",87.3,,,percent of total billed charges,,,12.87,,,fee schedule,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,18.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.37,,,fee schedule,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,11.2,,,fee schedule,,,12.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,12.87,,,fee schedule,,,12.87,,,fee schedule,,,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 9 PTC XMAS,3079787,CDM,305,RC,85250,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 9 PTC XMAS,3079787,CDM,305,RC,85250,CPT,,,,,,outpatient,facility,,,79,33.18,14.02,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,19.04,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,19.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,19.04,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,27.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.7,,,fee schedule,,,16.91,,,fee schedule,,,16.91,,,fee schedule,,,16.57,,,fee schedule,,,19.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,19.04,,,fee schedule,,,19.04,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 5 LABILE,3079795,CDM,305,RC,85220,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 5 LABILE,3079795,CDM,305,RC,85220,CPT,,,,,,outpatient,facility,,,75,31.5,14.02,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,17.65,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,17.65,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,25.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.83,,,fee schedule,,,15.67,,,fee schedule,,,15.67,,,fee schedule,,,15.36,,,fee schedule,,,17.65,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,17.65,,,fee schedule,,,17.65,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 7,3079803,CDM,305,RC,85230,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 7,3079803,CDM,305,RC,85230,CPT,,,,,,outpatient,facility,,,76,31.92,14.02,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,17.9,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,18.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,17.9,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,25.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.16,,,fee schedule,,,15.9,,,fee schedule,,,15.9,,,fee schedule,,,15.58,,,fee schedule,,,17.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,17.9,,,fee schedule,,,17.9,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 8 VWF AG,3079829,CDM,305,RC,85246,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 8 VWF AG,3079829,CDM,305,RC,85246,CPT,,,,,,outpatient,facility,,,74,31.08,19.96,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,22.94,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,23.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,22.94,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,33.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.97,,,fee schedule,,,20.37,,,fee schedule,,,20.37,,,fee schedule,,,19.96,,,fee schedule,,,22.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,22.94,,,fee schedule,,,22.94,,,fee schedule,,,28.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 8 VWF MULTI,3079837,CDM,305,RC,85247,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 8 VWF MULTI,3079837,CDM,305,RC,85247,CPT,,,,,,outpatient,facility,,,69,28.98,18.63,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,22.94,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,23.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,22.94,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,33.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.97,,,fee schedule,,,20.37,,,fee schedule,,,20.37,,,fee schedule,,,19.96,,,fee schedule,,,22.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,22.94,,,fee schedule,,,22.94,,,fee schedule,,,28.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 8 VWF RIST,3079845,CDM,305,RC,85245,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 8 VWF RIST,3079845,CDM,305,RC,85245,CPT,,,,,,outpatient,facility,,,74,31.08,19.96,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,22.94,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,23.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,22.94,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,33.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.97,,,fee schedule,,,20.37,,,fee schedule,,,20.37,,,fee schedule,,,19.96,,,fee schedule,,,22.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,22.94,,,fee schedule,,,22.94,,,fee schedule,,,28.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 10 STUART PROWR,3079852,CDM,305,RC,85260,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 10 STUART PROWR,3079852,CDM,305,RC,85260,CPT,,,,,,outpatient,facility,,,76,31.92,14.02,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,17.9,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,18.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,17.9,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,25.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.16,,,fee schedule,,,15.9,,,fee schedule,,,15.9,,,fee schedule,,,15.58,,,fee schedule,,,17.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,17.9,,,fee schedule,,,17.9,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 11 PTA,3079860,CDM,305,RC,85270,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 11 PTA,3079860,CDM,305,RC,85270,CPT,,,,,,outpatient,facility,,,76,31.92,14.02,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,17.9,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,18.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,17.9,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,25.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.16,,,fee schedule,,,15.9,,,fee schedule,,,15.9,,,fee schedule,,,15.58,,,fee schedule,,,17.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,17.9,,,fee schedule,,,17.9,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 12 HAGEMAN,3079878,CDM,305,RC,85280,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 12 HAGEMAN,3079878,CDM,305,RC,85280,CPT,,,,,,outpatient,facility,,,76,31.92,14.02,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,19.35,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,19.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,19.35,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,28.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.12,,,fee schedule,,,17.18,,,fee schedule,,,17.18,,,fee schedule,,,16.84,,,fee schedule,,,19.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,19.35,,,fee schedule,,,19.35,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 13 SCR SOL,3079894,CDM,305,RC,85291,CPT,,,,,,inpatient,facility,,,28,11.76,23.8,26.88,,23.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24.36,,,percent of total billed charges,,,,,,,,,25.2,,,percent of total billed charges,,,26.88,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.04,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 13 SCR SOL,3079894,CDM,305,RC,85291,CPT,,,,,,outpatient,facility,,,28,11.76,7.56,26.88,,23.8,,,percent of total billed charges,,,7.56,,,percent of total billed charges,,,19.26,,,percent of total billed charges,,,18.84,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,9.11,,,fee schedule,,,24.36,,,percent of total billed charges,,,24.36,,,percent of total billed charges,,,23.8,,,percent of total billed charges,,,26.88,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,9.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.2,,,percent of total billed charges,,,9.11,,,fee schedule,,,26.04,,,percent of total billed charges,,,26.6,,,percent of total billed charges,,,13.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.3,,,fee schedule,,,8.09,,,fee schedule,,,8.09,,,fee schedule,,,7.93,,,fee schedule,,,9.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",21.87,,,percent of total billed charges,,,25.48,,,percent of total billed charges,,,9.11,,,fee schedule,,,9.11,,,fee schedule,,,10.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FDP FSP AGG SEMI QN,3079902,CDM,305,RC,85362,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FDP FSP AGG SEMI QN,3079902,CDM,305,RC,85362,CPT,,,,,,outpatient,facility,,,21,8.82,5.63,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.89,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,7.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.89,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,9.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.3,,,fee schedule,,,6.12,,,fee schedule,,,6.12,,,fee schedule,,,6,,,fee schedule,,,6.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.89,,,fee schedule,,,6.89,,,fee schedule,,,5.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRIIODOTHYRONINE T3 FREE TR DIA,3079928,CDM,301,RC,84481,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIIODOTHYRONINE T3 FREE TR DIA,3079928,CDM,301,RC,84481,CPT,,,,,,outpatient,facility,,,71,29.82,14.74,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,16.94,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,17.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,16.94,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,24.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.87,,,fee schedule,,,15.04,,,fee schedule,,,15.04,,,fee schedule,,,14.74,,,fee schedule,,,16.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,16.94,,,fee schedule,,,16.94,,,fee schedule,,,20.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR ALLG IGE QL MULTI NS,3079944,CDM,302,RC,86005,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR ALLG IGE QL MULTI NS,3079944,CDM,302,RC,86005,CPT,,,,,,outpatient,facility,,,59,24.78,6.94,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,7.97,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,8.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,7.97,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.76,,,fee schedule,,,7.08,,,fee schedule,,,7.08,,,fee schedule,,,6.94,,,fee schedule,,,7.97,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,7.97,,,fee schedule,,,7.97,,,fee schedule,,,8.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB MOG FL,3079951,CDM,302,RC,86362,CPT,,,,,,inpatient,facility,,,86,36.12,73.1,82.56,,73.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,77.4,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB MOG FL,3079951,CDM,302,RC,86362,CPT,,,,,,outpatient,facility,,,86,36.12,10.49,82.56,,73.1,,,percent of total billed charges,,,23.22,,,percent of total billed charges,,,59.17,,,percent of total billed charges,,,57.88,,,percent of total billed charges,,,72.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,74.82,,,percent of total billed charges,,,74.82,,,percent of total billed charges,,,73.1,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",77.4,,,percent of total billed charges,,,12.05,,,fee schedule,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",67.17,,,percent of total billed charges,,,78.26,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,12.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER MOG,3079969,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,837,351.54,711.45,803.52,,711.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728.19,,,percent of total billed charges,,,,,,,,,753.3,,,percent of total billed charges,,,803.52,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,778.41,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER MOG,3079969,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,837,351.54,10.49,803.52,,711.45,,,percent of total billed charges,,,225.99,,,percent of total billed charges,,,575.86,,,percent of total billed charges,,,563.3,,,percent of total billed charges,,,707.26,,,percent of total billed charges,,,12.05,,,fee schedule,,,728.19,,,percent of total billed charges,,,728.19,,,percent of total billed charges,,,711.45,,,percent of total billed charges,,,803.52,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",753.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,778.41,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",653.7,,,percent of total billed charges,,,761.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG IGA SERUM NS,3079977,CDM,301,RC,82784,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG IGA SERUM NS,3079977,CDM,301,RC,82784,CPT,,,,,,outpatient,facility,,,56,23.52,8.09,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,9.3,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,9.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,9.3,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,13.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.56,,,fee schedule,,,8.26,,,fee schedule,,,8.26,,,fee schedule,,,8.09,,,fee schedule,,,9.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,9.3,,,fee schedule,,,9.3,,,fee schedule,,,11.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB LRP4 AUTO FL,3080041,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,850,357,722.5,816,,722.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,739.5,,,percent of total billed charges,,,,,,,,,765,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB LRP4 AUTO FL,3080041,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,850,357,10.49,816,,722.5,,,percent of total billed charges,,,229.5,,,percent of total billed charges,,,584.8,,,percent of total billed charges,,,572.05,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,12.05,,,fee schedule,,,739.5,,,percent of total billed charges,,,739.5,,,percent of total billed charges,,,722.5,,,percent of total billed charges,,,816,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",765,,,percent of total billed charges,,,12.05,,,fee schedule,,,790.5,,,percent of total billed charges,,,807.5,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",663.85,,,percent of total billed charges,,,773.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB RECEPTOR INTERLEUK 2 SOL N END,3080074,CDM,301,RC,84238,CPT,,,,,,inpatient,facility,,,500,210,425,480,,425,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,435,,,percent of total billed charges,,,,,,,,,450,,,percent of total billed charges,,,480,,,percent of total billed charges,,,475,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465,,,percent of total billed charges,,,475,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RECEPTOR INTERLEUK 2 SOL N END,3080074,CDM,301,RC,84238,CPT,,,,,,outpatient,facility,,,500,210,31.82,480,,425,,,percent of total billed charges,,,135,,,percent of total billed charges,,,344,,,percent of total billed charges,,,336.5,,,percent of total billed charges,,,422.5,,,percent of total billed charges,,,36.57,,,fee schedule,,,435,,,percent of total billed charges,,,435,,,percent of total billed charges,,,425,,,percent of total billed charges,,,480,,,percent of total billed charges,,,475,,,percent of total billed charges,,,37.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",450,,,percent of total billed charges,,,36.57,,,fee schedule,,,465,,,percent of total billed charges,,,475,,,percent of total billed charges,,,53.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.37,,,fee schedule,,,32.47,,,fee schedule,,,32.47,,,fee schedule,,,31.82,,,fee schedule,,,36.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",390.5,,,percent of total billed charges,,,455,,,percent of total billed charges,,,36.57,,,fee schedule,,,36.57,,,fee schedule,,,44.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HGB FETAL KLEIHAUER BETKE,3086014,CDM,305,RC,85460,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HGB FETAL KLEIHAUER BETKE,3086014,CDM,305,RC,85460,CPT,,,,,,outpatient,facility,,,59,24.78,6.72,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,7.73,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,7.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,7.73,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.44,,,fee schedule,,,6.86,,,fee schedule,,,6.86,,,fee schedule,,,6.72,,,fee schedule,,,7.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,7.73,,,fee schedule,,,7.73,,,fee schedule,,,9.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HGB FETAL ROSETTE,3086022,CDM,305,RC,85461,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HGB FETAL ROSETTE,3086022,CDM,305,RC,85461,CPT,,,,,,outpatient,facility,,,29,12.18,7.83,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.36,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.36,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.64,,,fee schedule,,,8.31,,,fee schedule,,,8.31,,,fee schedule,,,8.14,,,fee schedule,,,9.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.36,,,fee schedule,,,9.36,,,fee schedule,,,8.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FDP D DIMER QN,3086055,CDM,305,RC,85379,CPT,,,,,,inpatient,facility,,,31,13.02,26.35,29.76,,26.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,,,,,,,27.9,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.83,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FDP D DIMER QN,3086055,CDM,305,RC,85379,CPT,,,,,,outpatient,facility,,,31,13.02,8.37,29.76,,26.35,,,percent of total billed charges,,,8.37,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,20.86,,,percent of total billed charges,,,26.2,,,percent of total billed charges,,,10.18,,,fee schedule,,,26.97,,,percent of total billed charges,,,26.97,,,percent of total billed charges,,,26.35,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.9,,,percent of total billed charges,,,10.18,,,fee schedule,,,28.83,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,14.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.74,,,fee schedule,,,9.04,,,fee schedule,,,9.04,,,fee schedule,,,8.86,,,fee schedule,,,10.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",24.21,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,10.18,,,fee schedule,,,10.18,,,fee schedule,,,9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FIBRINOGEN ACTIVITY,3086063,CDM,305,RC,85384,CPT,,,,,,inpatient,facility,,,30,12.6,25.5,28.8,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,27,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FIBRINOGEN ACTIVITY,3086063,CDM,305,RC,85384,CPT,,,,,,outpatient,facility,,,30,12.6,8.1,28.8,,25.5,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,20.64,,,percent of total billed charges,,,20.19,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,9.72,,,fee schedule,,,26.1,,,percent of total billed charges,,,26.1,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27,,,percent of total billed charges,,,9.72,,,fee schedule,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,14.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.12,,,fee schedule,,,8.63,,,fee schedule,,,8.63,,,fee schedule,,,8.46,,,fee schedule,,,9.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",23.43,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,9.72,,,fee schedule,,,9.72,,,fee schedule,,,10.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FIBRINOGEN ANTIGEN,3086071,CDM,305,RC,85385,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FIBRINOGEN ANTIGEN,3086071,CDM,305,RC,85385,CPT,,,,,,outpatient,facility,,,44,18.48,10.41,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.46,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.46,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,20.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.52,,,fee schedule,,,12.84,,,fee schedule,,,12.84,,,fee schedule,,,12.58,,,fee schedule,,,14.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.46,,,fee schedule,,,14.46,,,fee schedule,,,10.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD HEMATOCRIT,3086097,CDM,305,RC,85014,CPT,,,,,,inpatient,facility,,,8,3.36,6.8,7.68,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD HEMATOCRIT,3086097,CDM,305,RC,85014,CPT,,,,,,outpatient,facility,,,8,3.36,2.06,7.68,,6.8,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,2.37,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.2,,,percent of total billed charges,,,2.37,,,fee schedule,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,2.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMO PLT AUTO W AUTO SCAN,3086113,CDM,305,RC,85025,CPT,,,,,,inpatient,facility,,,24,10.08,20.4,23.04,,20.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,21.6,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMO PLT AUTO W AUTO SCAN,3086113,CDM,305,RC,85025,CPT,,,,,,outpatient,facility,,,24,10.08,6.48,23.04,,20.4,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,16.51,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,20.28,,,percent of total billed charges,,,7.77,,,fee schedule,,,20.88,,,percent of total billed charges,,,20.88,,,percent of total billed charges,,,20.4,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,7.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.6,,,percent of total billed charges,,,7.77,,,fee schedule,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,11.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.49,,,fee schedule,,,6.9,,,fee schedule,,,6.9,,,fee schedule,,,6.76,,,fee schedule,,,7.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",18.74,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,7.77,,,fee schedule,,,7.77,,,fee schedule,,,9.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD HEMOGLOBIN,3086121,CDM,305,RC,85018,CPT,,,,,,inpatient,facility,,,8,3.36,6.8,7.68,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD HEMOGLOBIN,3086121,CDM,305,RC,85018,CPT,,,,,,outpatient,facility,,,8,3.36,1.95,7.68,,6.8,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,2.37,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.2,,,percent of total billed charges,,,2.37,,,fee schedule,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,1.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ASSAY HEPARIN,3086147,CDM,305,RC,85520,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ASSAY HEPARIN,3086147,CDM,305,RC,85520,CPT,,,,,,outpatient,facility,,,65,27.3,11.39,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.09,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.09,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,18.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.67,,,fee schedule,,,11.62,,,fee schedule,,,11.62,,,fee schedule,,,11.39,,,fee schedule,,,13.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.09,,,fee schedule,,,13.09,,,fee schedule,,,16.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MURAMIDASE,3086188,CDM,305,RC,85549,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MURAMIDASE,3086188,CDM,305,RC,85549,CPT,,,,,,outpatient,facility,,,57,23.94,15.39,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,18.75,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,18.75,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,27.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.31,,,fee schedule,,,16.65,,,fee schedule,,,16.65,,,fee schedule,,,16.32,,,fee schedule,,,18.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,18.75,,,fee schedule,,,18.75,,,fee schedule,,,23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FRAGILITY OSMOTIC RBC INCUB,3086196,CDM,305,RC,85557,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FRAGILITY OSMOTIC RBC INCUB,3086196,CDM,305,RC,85557,CPT,,,,,,outpatient,facility,,,57,23.94,11.62,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,13.36,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,13.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,13.36,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,19.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.04,,,fee schedule,,,11.86,,,fee schedule,,,11.86,,,fee schedule,,,11.62,,,fee schedule,,,13.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,16.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PLASMINOGEN NON ANTIGENIC,3086238,CDM,305,RC,85420,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PLASMINOGEN NON ANTIGENIC,3086238,CDM,305,RC,85420,CPT,,,,,,outpatient,facility,,,57,23.94,5.68,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,6.53,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,6.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,6.53,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,9.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.82,,,fee schedule,,,5.8,,,fee schedule,,,5.8,,,fee schedule,,,5.68,,,fee schedule,,,6.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,6.53,,,fee schedule,,,6.53,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING ACT PROTEIN C,3086261,CDM,305,RC,85303,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING ACT PROTEIN C,3086261,CDM,305,RC,85303,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.84,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,14.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.84,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,20.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.68,,,fee schedule,,,12.29,,,fee schedule,,,12.29,,,fee schedule,,,12.04,,,fee schedule,,,13.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.84,,,fee schedule,,,13.84,,,fee schedule,,,16.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING AG PROTEIN C,3086279,CDM,305,RC,85302,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING AG PROTEIN C,3086279,CDM,305,RC,85302,CPT,,,,,,outpatient,facility,,,65,27.3,10.45,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,12.01,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,12.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,12.01,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,17.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.21,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,12.01,,,fee schedule,,,12.01,,,fee schedule,,,14.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING PROTEIN S FREE,3086287,CDM,305,RC,85306,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING PROTEIN S FREE,3086287,CDM,305,RC,85306,CPT,,,,,,outpatient,facility,,,66,27.72,13.33,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,15.32,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,15.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,15.32,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,22.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.68,,,fee schedule,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.33,,,fee schedule,,,15.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,15.32,,,fee schedule,,,15.32,,,fee schedule,,,14.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROTHROMBIN TIME,3086303,CDM,305,RC,85610,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROTHROMBIN TIME,3086303,CDM,305,RC,85610,CPT,,,,,,outpatient,facility,,,51,21.42,3.73,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,4.29,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,4.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,4.29,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,6.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.79,,,fee schedule,,,3.81,,,fee schedule,,,3.81,,,fee schedule,,,3.73,,,fee schedule,,,4.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,4.29,,,fee schedule,,,4.29,,,fee schedule,,,3.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROTHROMBIN TIME SUB,3086311,CDM,305,RC,85611,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROTHROMBIN TIME SUB,3086311,CDM,305,RC,85611,CPT,,,,,,outpatient,facility,,,58,24.36,3.43,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,3.94,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,4.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,3.94,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,5.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.32,,,fee schedule,,,3.5,,,fee schedule,,,3.5,,,fee schedule,,,3.43,,,fee schedule,,,3.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,3.94,,,fee schedule,,,3.94,,,fee schedule,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PTT SUBSTITUTION FRAC PLASMA,3086329,CDM,305,RC,85732,CPT,,,,,,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PTT SUBSTITUTION FRAC PLASMA,3086329,CDM,305,RC,85732,CPT,,,,,,outpatient,facility,,,103,43.26,5.64,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,6.47,,,fee schedule,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",92.7,,,percent of total billed charges,,,6.47,,,fee schedule,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,6.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB REPTILASE,3086337,CDM,305,RC,85635,CPT,,,,,,inpatient,facility,,,30,12.6,25.5,28.8,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,27,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB REPTILASE,3086337,CDM,305,RC,85635,CPT,,,,,,outpatient,facility,,,30,12.6,8.1,28.8,,25.5,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,20.64,,,percent of total billed charges,,,20.19,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,9.85,,,fee schedule,,,26.1,,,percent of total billed charges,,,26.1,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,10.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27,,,percent of total billed charges,,,9.85,,,fee schedule,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,14.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.3,,,fee schedule,,,8.75,,,fee schedule,,,8.75,,,fee schedule,,,8.57,,,fee schedule,,,9.85,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",23.43,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,9.85,,,fee schedule,,,9.85,,,fee schedule,,,12.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VENOM TIME RUSSELL VIPER DLT,3086345,CDM,305,RC,85613,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VENOM TIME RUSSELL VIPER DLT,3086345,CDM,305,RC,85613,CPT,,,,,,outpatient,facility,,,60,25.2,8.34,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,9.58,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,9.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,9.58,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,13.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.93,,,fee schedule,,,8.51,,,fee schedule,,,8.51,,,fee schedule,,,8.34,,,fee schedule,,,9.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,9.58,,,fee schedule,,,9.58,,,fee schedule,,,11.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB RATE SEDIMENTATION RBC AUTO,3086360,CDM,305,RC,85652,CPT,,,,,,inpatient,facility,,,9,3.78,7.65,8.64,,7.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7.83,,,percent of total billed charges,,,,,,,,,8.1,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8.37,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RATE SEDIMENTATION RBC AUTO,3086360,CDM,305,RC,85652,CPT,,,,,,outpatient,facility,,,9,3.78,2.35,8.64,,7.65,,,percent of total billed charges,,,2.43,,,percent of total billed charges,,,6.19,,,percent of total billed charges,,,6.06,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.7,,,fee schedule,,,7.83,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,7.65,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,2.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.1,,,percent of total billed charges,,,2.7,,,fee schedule,,,8.37,,,percent of total billed charges,,,8.55,,,percent of total billed charges,,,3.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.65,,,fee schedule,,,2.4,,,fee schedule,,,2.4,,,fee schedule,,,2.35,,,fee schedule,,,2.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",7.03,,,percent of total billed charges,,,8.19,,,percent of total billed charges,,,2.7,,,fee schedule,,,2.7,,,fee schedule,,,3.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB RATE SEDIMENTATION RBC NONAUTO,3086378,CDM,305,RC,85651,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RATE SEDIMENTATION RBC NONAUTO,3086378,CDM,305,RC,85651,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.27,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.27,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,4.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THROMBIN TIME PLASMA,3086402,CDM,305,RC,85670,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THROMBIN TIME PLASMA,3086402,CDM,305,RC,85670,CPT,,,,,,outpatient,facility,,,56,23.52,5.02,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.77,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.77,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,8.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.79,,,fee schedule,,,5.12,,,fee schedule,,,5.12,,,fee schedule,,,5.02,,,fee schedule,,,5.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.77,,,fee schedule,,,5.77,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PTT PLASMA BLD WHL,3086428,CDM,305,RC,85730,CPT,,,,,,inpatient,facility,,,19,7.98,16.15,18.24,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16.53,,,percent of total billed charges,,,,,,,,,17.1,,,percent of total billed charges,,,18.24,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17.67,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PTT PLASMA BLD WHL,3086428,CDM,305,RC,85730,CPT,,,,,,outpatient,facility,,,19,7.98,5.13,18.24,,16.15,,,percent of total billed charges,,,5.13,,,percent of total billed charges,,,13.07,,,percent of total billed charges,,,12.79,,,percent of total billed charges,,,16.05,,,percent of total billed charges,,,6.01,,,fee schedule,,,16.53,,,percent of total billed charges,,,16.53,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,18.24,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,6.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.1,,,percent of total billed charges,,,6.01,,,fee schedule,,,17.67,,,percent of total billed charges,,,18.05,,,percent of total billed charges,,,8.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.11,,,fee schedule,,,5.34,,,fee schedule,,,5.34,,,fee schedule,,,5.23,,,fee schedule,,,6.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.84,,,percent of total billed charges,,,17.29,,,percent of total billed charges,,,6.01,,,fee schedule,,,6.01,,,fee schedule,,,7.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VISCOSITY,3086444,CDM,305,RC,85810,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VISCOSITY,3086444,CDM,305,RC,85810,CPT,,,,,,outpatient,facility,,,57,23.94,10.15,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,11.67,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,11.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,11.67,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,16.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.75,,,fee schedule,,,10.36,,,fee schedule,,,10.36,,,fee schedule,,,10.15,,,fee schedule,,,11.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,11.67,,,fee schedule,,,11.67,,,fee schedule,,,14.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA BARTONELLA PRB AMP,3086469,CDM,306,RC,87471,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA BARTONELLA PRB AMP,3086469,CDM,306,RC,87471,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA CHLAMYD TRAC PRB AMP,3086493,CDM,306,RC,87491,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CHLAMYD TRAC PRB AMP,3086493,CDM,306,RC,87491,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA CMV PRB AMP NS,3086519,CDM,306,RC,87496,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CMV PRB AMP NS,3086519,CDM,306,RC,87496,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA CMV QN NS,3086527,CDM,306,RC,87497,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CMV QN NS,3086527,CDM,306,RC,87497,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONCENTRATION AFB IA,3086535,CDM,306,RC,87015,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONCENTRATION AFB IA,3086535,CDM,306,RC,87015,CPT,,,,,,outpatient,facility,,,21,8.82,5.34,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.68,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,6.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.68,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,9.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.02,,,fee schedule,,,5.93,,,fee schedule,,,5.93,,,fee schedule,,,5.81,,,fee schedule,,,6.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.68,,,fee schedule,,,6.68,,,fee schedule,,,5.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONCENTRATION ANY TYPE IA,3086543,CDM,306,RC,87015,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONCENTRATION ANY TYPE IA,3086543,CDM,306,RC,87015,CPT,,,,,,outpatient,facility,,,21,8.82,5.34,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.68,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,6.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.68,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,9.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.02,,,fee schedule,,,5.93,,,fee schedule,,,5.93,,,fee schedule,,,5.81,,,fee schedule,,,6.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.68,,,fee schedule,,,6.68,,,fee schedule,,,5.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC ID DF,3086550,CDM,306,RC,87077,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC ID DF,3086550,CDM,306,RC,87077,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.08,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.08,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.91,,,fee schedule,,,7.18,,,fee schedule,,,7.18,,,fee schedule,,,7.04,,,fee schedule,,,8.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.08,,,fee schedule,,,8.08,,,fee schedule,,,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC OTHER QN,3086568,CDM,306,RC,87071,CPT,,,,,,inpatient,facility,,,30,12.6,25.5,28.8,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,27,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC OTHER QN,3086568,CDM,306,RC,87071,CPT,,,,,,outpatient,facility,,,30,12.6,4.6,28.8,,25.5,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,20.64,,,percent of total billed charges,,,20.19,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,9.89,,,fee schedule,,,26.1,,,percent of total billed charges,,,26.1,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,10.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27,,,percent of total billed charges,,,9.89,,,fee schedule,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,14.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.35,,,fee schedule,,,8.78,,,fee schedule,,,8.78,,,fee schedule,,,8.6,,,fee schedule,,,9.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",23.43,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,9.89,,,fee schedule,,,9.89,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT AFB ID ISOLATES,3086576,CDM,306,RC,87116,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT AFB ID ISOLATES,3086576,CDM,306,RC,87116,CPT,,,,,,outpatient,facility,,,63,26.46,9.4,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,10.8,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,11.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,10.8,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,15.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.58,,,fee schedule,,,9.59,,,fee schedule,,,9.59,,,fee schedule,,,9.4,,,fee schedule,,,10.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,10.8,,,fee schedule,,,10.8,,,fee schedule,,,13.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT AFB ID ISOLATES BLOOD,3086584,CDM,306,RC,87116,CPT,,,,,,inpatient,facility,,,33,13.86,28.05,31.68,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.71,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT AFB ID ISOLATES BLOOD,3086584,CDM,306,RC,87116,CPT,,,,,,outpatient,facility,,,33,13.86,8.91,31.68,,28.05,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.21,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,10.8,,,fee schedule,,,28.71,,,percent of total billed charges,,,28.71,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,11.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.7,,,percent of total billed charges,,,10.8,,,fee schedule,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,15.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.58,,,fee schedule,,,9.59,,,fee schedule,,,9.59,,,fee schedule,,,9.4,,,fee schedule,,,10.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",25.77,,,percent of total billed charges,,,30.03,,,percent of total billed charges,,,10.8,,,fee schedule,,,10.8,,,fee schedule,,,13.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT ANAEROBIC OTHER,3086592,CDM,306,RC,87075,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT ANAEROBIC OTHER,3086592,CDM,306,RC,87075,CPT,,,,,,outpatient,facility,,,29,12.18,7.83,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.47,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.47,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.78,,,fee schedule,,,8.41,,,fee schedule,,,8.41,,,fee schedule,,,8.24,,,fee schedule,,,9.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.47,,,fee schedule,,,9.47,,,fee schedule,,,11.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT ANAEROBIC ID DF,3086600,CDM,306,RC,87076,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT ANAEROBIC ID DF,3086600,CDM,306,RC,87076,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.08,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.08,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.91,,,fee schedule,,,7.18,,,fee schedule,,,7.18,,,fee schedule,,,7.04,,,fee schedule,,,8.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.08,,,fee schedule,,,8.08,,,fee schedule,,,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC BLOOD,3086618,CDM,306,RC,87040,CPT,,,,,,inpatient,facility,,,31,13.02,26.35,29.76,,26.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,,,,,,,27.9,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.83,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC BLOOD,3086618,CDM,306,RC,87040,CPT,,,,,,outpatient,facility,,,31,13.02,4.6,29.76,,26.35,,,percent of total billed charges,,,8.37,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,20.86,,,percent of total billed charges,,,26.2,,,percent of total billed charges,,,10.32,,,fee schedule,,,26.97,,,percent of total billed charges,,,26.97,,,percent of total billed charges,,,26.35,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,10.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.9,,,percent of total billed charges,,,10.32,,,fee schedule,,,28.83,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,14.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.93,,,fee schedule,,,9.16,,,fee schedule,,,9.16,,,fee schedule,,,8.98,,,fee schedule,,,10.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",24.21,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,10.32,,,fee schedule,,,10.32,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC CATHETER TIP,3086626,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC CATHETER TIP,3086626,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT CHLAMYDIA,3086634,CDM,306,RC,87110,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT CHLAMYDIA,3086634,CDM,306,RC,87110,CPT,,,,,,outpatient,facility,,,71,29.82,17.05,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,19.6,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,19.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,19.6,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,28.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.46,,,fee schedule,,,17.4,,,fee schedule,,,17.4,,,fee schedule,,,17.05,,,fee schedule,,,19.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,19.6,,,fee schedule,,,19.6,,,fee schedule,,,30.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC CSF,3086642,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC CSF,3086642,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISO VIRUS SHELL VIAL ID W IF,3086659,CDM,306,RC,87254,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISO VIRUS SHELL VIAL ID W IF,3086659,CDM,306,RC,87254,CPT,,,,,,outpatient,facility,,,64,26.88,14.99,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,19.56,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,19.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,19.56,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,28.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.41,,,fee schedule,,,17.37,,,fee schedule,,,17.37,,,fee schedule,,,17.02,,,fee schedule,,,19.56,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,19.56,,,fee schedule,,,19.56,,,fee schedule,,,14.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC EAR,3086667,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC EAR,3086667,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC EYE,3086683,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC EYE,3086683,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,61,25.62,4.6,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,8.62,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,8.62,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI ID ISOLATES BLOOD,3086691,CDM,306,RC,87103,CPT,,,,,,inpatient,facility,,,127,53.34,107.95,121.92,,107.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.49,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI ID ISOLATES BLOOD,3086691,CDM,306,RC,87103,CPT,,,,,,outpatient,facility,,,127,53.34,11.06,121.92,,107.95,,,percent of total billed charges,,,34.29,,,percent of total billed charges,,,87.38,,,percent of total billed charges,,,85.47,,,percent of total billed charges,,,107.31,,,percent of total billed charges,,,20.46,,,fee schedule,,,110.49,,,percent of total billed charges,,,110.49,,,percent of total billed charges,,,107.95,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",114.3,,,percent of total billed charges,,,20.46,,,fee schedule,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,29.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.62,,,fee schedule,,,18.17,,,fee schedule,,,18.17,,,fee schedule,,,17.81,,,fee schedule,,,20.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.19,,,percent of total billed charges,,,115.57,,,percent of total billed charges,,,20.46,,,fee schedule,,,20.46,,,fee schedule,,,11.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI ID DERMATOPHYTE,3086709,CDM,306,RC,87101,CPT,,,,,,inpatient,facility,,,24,10.08,20.4,23.04,,20.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,21.6,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI ID DERMATOPHYTE,3086709,CDM,306,RC,87101,CPT,,,,,,outpatient,facility,,,24,10.08,5.13,23.04,,20.4,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,16.51,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,20.28,,,percent of total billed charges,,,7.71,,,fee schedule,,,20.88,,,percent of total billed charges,,,20.88,,,percent of total billed charges,,,20.4,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,7.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.6,,,percent of total billed charges,,,7.71,,,fee schedule,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,11.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.41,,,fee schedule,,,6.85,,,fee schedule,,,6.85,,,fee schedule,,,6.71,,,fee schedule,,,7.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",18.74,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,7.71,,,fee schedule,,,7.71,,,fee schedule,,,5.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI ID DF MOLD,3086717,CDM,306,RC,87107,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI ID DF MOLD,3086717,CDM,306,RC,87107,CPT,,,,,,outpatient,facility,,,62,26.04,4.6,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,10.32,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,10.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,10.32,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,14.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.93,,,fee schedule,,,9.16,,,fee schedule,,,9.16,,,fee schedule,,,8.98,,,fee schedule,,,10.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,10.32,,,fee schedule,,,10.32,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI ID DF YEAST,3086725,CDM,306,RC,87106,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI ID DF YEAST,3086725,CDM,306,RC,87106,CPT,,,,,,outpatient,facility,,,62,26.04,4.6,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,10.32,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,10.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,10.32,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,14.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.93,,,fee schedule,,,9.16,,,fee schedule,,,9.16,,,fee schedule,,,8.98,,,fee schedule,,,10.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,10.32,,,fee schedule,,,10.32,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI ID ISOLATES,3086733,CDM,306,RC,87102,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI ID ISOLATES,3086733,CDM,306,RC,87102,CPT,,,,,,outpatient,facility,,,78,32.76,5.13,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,8.41,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,8.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,8.41,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,12.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.35,,,fee schedule,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.32,,,fee schedule,,,8.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,8.41,,,fee schedule,,,8.41,,,fee schedule,,,5.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC GENITAL,3086741,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC GENITAL,3086741,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC RESP LOWER,3086758,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC RESP LOWER,3086758,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT MYCOPLASMA UREAPLASMA,3086766,CDM,306,RC,87109,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT MYCOPLASMA UREAPLASMA,3086766,CDM,306,RC,87109,CPT,,,,,,outpatient,facility,,,63,26.46,5.13,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,15.39,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,15.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,15.39,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,22.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.78,,,fee schedule,,,13.67,,,fee schedule,,,13.67,,,fee schedule,,,13.4,,,fee schedule,,,15.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,15.39,,,fee schedule,,,15.39,,,fee schedule,,,5.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT MYCOBACTERIAL ID DF,3086774,CDM,306,RC,87118,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT MYCOBACTERIAL ID DF,3086774,CDM,306,RC,87118,CPT,,,,,,outpatient,facility,,,64,26.88,12.71,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,14.61,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,14.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,14.61,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,21.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.72,,,fee schedule,,,12.97,,,fee schedule,,,12.97,,,fee schedule,,,12.71,,,fee schedule,,,14.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,14.61,,,fee schedule,,,14.61,,,fee schedule,,,13.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC ID DF NOCARD,3086790,CDM,306,RC,87077,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC ID DF NOCARD,3086790,CDM,306,RC,87077,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.08,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.08,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.91,,,fee schedule,,,7.18,,,fee schedule,,,7.18,,,fee schedule,,,7.04,,,fee schedule,,,8.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.08,,,fee schedule,,,8.08,,,fee schedule,,,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC OTHER,3086808,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC OTHER,3086808,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,75,31.5,4.6,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,8.62,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,8.62,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT BORDETELLA,3086824,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT BORDETELLA,3086824,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,20,8.4,5.16,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.63,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.63,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT GONORRHEA,3086840,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT GONORRHEA,3086840,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,58,24.36,5.16,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,6.63,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT LEGIONELLA,3086857,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT LEGIONELLA,3086857,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,20,8.4,5.16,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.63,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.63,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT ORGANISMS SGL,3086865,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT ORGANISMS SGL,3086865,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,59,24.78,5.16,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,6.63,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,6.63,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT STAPH MRSA,3086873,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT STAPH MRSA,3086873,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,20,8.4,5.16,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.63,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.63,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT STREP GROUP B,3086881,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT STREP GROUP B,3086881,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,20,8.4,5.16,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.63,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.63,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT VRE,3086899,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT VRE,3086899,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,58,24.36,5.16,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,6.63,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT FLUID BODY STERILE,3086915,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT FLUID BODY STERILE,3086915,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC STOOL CAMPY,3086931,CDM,306,RC,87046,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC STOOL CAMPY,3086931,CDM,306,RC,87046,CPT,,,,,,outpatient,facility,,,29,12.18,4.6,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.44,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.44,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC STOOL E COLI,3086949,CDM,306,RC,87046,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC STOOL E COLI,3086949,CDM,306,RC,87046,CPT,,,,,,outpatient,facility,,,29,12.18,4.6,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.44,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.44,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC STOOL PATH,3086956,CDM,306,RC,87046,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC STOOL PATH,3086956,CDM,306,RC,87046,CPT,,,,,,outpatient,facility,,,29,12.18,4.6,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.44,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.44,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC STOOL,3086964,CDM,306,RC,87045,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC STOOL,3086964,CDM,306,RC,87045,CPT,,,,,,outpatient,facility,,,29,12.18,4.6,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.44,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.44,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC STOOL VIBRO,3086972,CDM,306,RC,87046,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC STOOL VIBRO,3086972,CDM,306,RC,87046,CPT,,,,,,outpatient,facility,,,29,12.18,4.6,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.44,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.44,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC STOOL YERSNIA,3086980,CDM,306,RC,87046,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC STOOL YERSNIA,3086980,CDM,306,RC,87046,CPT,,,,,,outpatient,facility,,,29,12.18,4.6,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.44,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.44,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC TISSUE,3086998,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,112,47.04,95.2,107.52,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC TISSUE,3086998,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,112,47.04,4.6,107.52,,95.2,,,percent of total billed charges,,,30.24,,,percent of total billed charges,,,77.06,,,percent of total billed charges,,,75.38,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,8.62,,,fee schedule,,,97.44,,,percent of total billed charges,,,97.44,,,percent of total billed charges,,,95.2,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.8,,,percent of total billed charges,,,8.62,,,fee schedule,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",87.47,,,percent of total billed charges,,,101.92,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING ID NUC ACID PRB DIR,3087004,CDM,306,RC,87149,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING ID NUC ACID PRB DIR,3087004,CDM,306,RC,87149,CPT,,,,,,outpatient,facility,,,73,30.66,17.44,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,20.05,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,20.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,20.05,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,29.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.07,,,fee schedule,,,17.8,,,fee schedule,,,17.8,,,fee schedule,,,17.44,,,fee schedule,,,20.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,20.05,,,fee schedule,,,20.05,,,fee schedule,,,24.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING GLC HPLC,3087012,CDM,306,RC,87143,CPT,,,,,,inpatient,facility,,,38,15.96,32.3,36.48,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,,,,,,,34.2,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING GLC HPLC,3087012,CDM,306,RC,87143,CPT,,,,,,outpatient,facility,,,38,15.96,10.26,36.48,,32.3,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,26.14,,,percent of total billed charges,,,25.57,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,12.52,,,fee schedule,,,33.06,,,percent of total billed charges,,,33.06,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,12.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.2,,,percent of total billed charges,,,12.52,,,fee schedule,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,18.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.9,,,fee schedule,,,11.12,,,fee schedule,,,11.12,,,fee schedule,,,10.9,,,fee schedule,,,12.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",29.68,,,percent of total billed charges,,,34.58,,,percent of total billed charges,,,12.52,,,fee schedule,,,12.52,,,fee schedule,,,15.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING IF ANTISERUM EA,3087020,CDM,306,RC,87140,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING IF ANTISERUM EA,3087020,CDM,306,RC,87140,CPT,,,,,,outpatient,facility,,,57,23.94,4.44,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,5.57,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,5.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,5.57,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,8.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.52,,,fee schedule,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,4.85,,,fee schedule,,,5.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,5.57,,,fee schedule,,,5.57,,,fee schedule,,,4.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING SEROLOGICAL,3087046,CDM,306,RC,87147,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING SEROLOGICAL,3087046,CDM,306,RC,87147,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.18,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.18,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC RESP UPPER,3087053,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC RESP UPPER,3087053,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT ID ISOLATE URINE,3087061,CDM,306,RC,87088,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT ID ISOLATE URINE,3087061,CDM,306,RC,87088,CPT,,,,,,outpatient,facility,,,25,10.5,4.6,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.09,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.09,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.92,,,fee schedule,,,7.18,,,fee schedule,,,7.18,,,fee schedule,,,7.04,,,fee schedule,,,8.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.09,,,fee schedule,,,8.09,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT COLONY COUNT URINE,3087079,CDM,306,RC,87086,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT COLONY COUNT URINE,3087079,CDM,306,RC,87086,CPT,,,,,,outpatient,facility,,,25,10.5,4.64,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.07,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.07,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.89,,,fee schedule,,,7.17,,,fee schedule,,,7.17,,,fee schedule,,,7.03,,,fee schedule,,,8.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.07,,,fee schedule,,,8.07,,,fee schedule,,,4.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISO VIRUS ID ACT ENZYMATIC,3087087,CDM,306,RC,87255,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISO VIRUS ID ACT ENZYMATIC,3087087,CDM,306,RC,87255,CPT,,,,,,outpatient,facility,,,102,42.84,27.54,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,33.86,,,fee schedule,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,34.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",91.8,,,percent of total billed charges,,,33.86,,,fee schedule,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,49.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.71,,,fee schedule,,,30.07,,,fee schedule,,,30.07,,,fee schedule,,,29.47,,,fee schedule,,,33.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,33.86,,,fee schedule,,,33.86,,,fee schedule,,,41.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISO VIRUS INOC TISSUE ADDL,3087095,CDM,306,RC,87253,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISO VIRUS INOC TISSUE ADDL,3087095,CDM,306,RC,87253,CPT,,,,,,outpatient,facility,,,65,27.3,17.55,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,20.2,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,20.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,20.2,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,29.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.27,,,fee schedule,,,17.94,,,fee schedule,,,17.94,,,fee schedule,,,17.58,,,fee schedule,,,20.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,20.2,,,fee schedule,,,20.2,,,fee schedule,,,24.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISO VIRUS INOC TISSUE,3087103,CDM,306,RC,87252,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISO VIRUS INOC TISSUE,3087103,CDM,306,RC,87252,CPT,,,,,,outpatient,facility,,,79,33.18,21.33,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,26.07,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,26.07,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,37.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.19,,,fee schedule,,,23.15,,,fee schedule,,,23.15,,,fee schedule,,,22.69,,,fee schedule,,,26.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,26.07,,,fee schedule,,,26.07,,,fee schedule,,,31.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC WOUND,3087129,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC WOUND,3087129,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,26,10.92,4.6,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.62,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.62,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI YEAST ID ISOLATES,3087137,CDM,306,RC,87102,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI YEAST ID ISOLATES,3087137,CDM,306,RC,87102,CPT,,,,,,outpatient,facility,,,60,25.2,5.13,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,8.41,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,8.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,8.41,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.35,,,fee schedule,,,7.47,,,fee schedule,,,7.47,,,fee schedule,,,7.32,,,fee schedule,,,8.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,8.41,,,fee schedule,,,8.41,,,fee schedule,,,5.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ TOXIN C DIFF,3087160,CDM,306,RC,87324,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ TOXIN C DIFF,3087160,CDM,306,RC,87324,CPT,,,,,,outpatient,facility,,,60,25.2,10.43,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,11.98,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,11.98,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM H PYLORI STOOL,3087210,CDM,306,RC,87338,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM H PYLORI STOOL,3087210,CDM,306,RC,87338,CPT,,,,,,outpatient,facility,,,75,31.5,12.51,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,14.38,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,14.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,14.38,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,20.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.41,,,fee schedule,,,12.77,,,fee schedule,,,12.77,,,fee schedule,,,12.51,,,fee schedule,,,14.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,14.38,,,fee schedule,,,14.38,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA HBSAG QL SEMI QN,3087228,CDM,306,RC,87340,CPT,,,,,,inpatient,facility,,,31,13.02,26.35,29.76,,26.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,,,,,,,27.9,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,28.83,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA HBSAG QL SEMI QN,3087228,CDM,306,RC,87340,CPT,,,,,,outpatient,facility,,,31,13.02,8.37,29.76,,26.35,,,percent of total billed charges,,,8.37,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,20.86,,,percent of total billed charges,,,26.2,,,percent of total billed charges,,,10.33,,,fee schedule,,,26.97,,,percent of total billed charges,,,26.97,,,percent of total billed charges,,,26.35,,,percent of total billed charges,,,29.76,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,10.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.9,,,percent of total billed charges,,,10.33,,,fee schedule,,,28.83,,,percent of total billed charges,,,29.45,,,percent of total billed charges,,,14.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.95,,,fee schedule,,,9.17,,,fee schedule,,,9.17,,,fee schedule,,,8.99,,,fee schedule,,,10.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",24.21,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,10.33,,,fee schedule,,,10.33,,,fee schedule,,,12.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ HEP BE,3087236,CDM,306,RC,87350,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ HEP BE,3087236,CDM,306,RC,87350,CPT,,,,,,outpatient,facility,,,59,24.78,10.04,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,11.53,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,11.53,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ HISTOPLASMA,3087244,CDM,306,RC,87385,CPT,,,,,,inpatient,facility,,,152,63.84,129.2,145.92,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.24,,,percent of total billed charges,,,,,,,,,136.8,,,percent of total billed charges,,,145.92,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ HISTOPLASMA,3087244,CDM,306,RC,87385,CPT,,,,,,outpatient,facility,,,152,63.84,11.53,145.92,,129.2,,,percent of total billed charges,,,41.04,,,percent of total billed charges,,,104.58,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,128.44,,,percent of total billed charges,,,13.25,,,fee schedule,,,132.24,,,percent of total billed charges,,,132.24,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,145.92,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",136.8,,,percent of total billed charges,,,13.25,,,fee schedule,,,141.36,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",118.71,,,percent of total billed charges,,,138.32,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ ROTAVIRUS,3087301,CDM,306,RC,87425,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ ROTAVIRUS,3087301,CDM,306,RC,87425,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.98,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ RSV,3087319,CDM,306,RC,87420,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ RSV,3087319,CDM,306,RC,87420,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.91,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,14.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.91,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,20.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.78,,,fee schedule,,,12.35,,,fee schedule,,,12.35,,,fee schedule,,,12.1,,,fee schedule,,,13.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.91,,,fee schedule,,,13.91,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ TOX SHIGA,3087327,CDM,306,RC,87427,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ TOX SHIGA,3087327,CDM,306,RC,87427,CPT,,,,,,outpatient,facility,,,80,33.6,10.43,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,11.98,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,11.98,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ STREP GROUP A,3087343,CDM,306,RC,87430,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ STREP GROUP A,3087343,CDM,306,RC,87430,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.81,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.81,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.69,,,fee schedule,,,14.93,,,fee schedule,,,14.93,,,fee schedule,,,14.63,,,fee schedule,,,16.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.81,,,fee schedule,,,16.81,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ QL,3087350,CDM,306,RC,87449,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ QL,3087350,CDM,306,RC,87449,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.98,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA GC PRB AMP,3087368,CDM,306,RC,87591,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA GC PRB AMP,3087368,CDM,306,RC,87591,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HERPES 6 PRB AMP,3087459,CDM,306,RC,87532,CPT,,,,,,inpatient,facility,,,120,50.4,102,115.2,,102,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,104.4,,,percent of total billed charges,,,,,,,,,108,,,percent of total billed charges,,,115.2,,,percent of total billed charges,,,114,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,111.6,,,percent of total billed charges,,,114,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HERPES 6 PRB AMP,3087459,CDM,306,RC,87532,CPT,,,,,,outpatient,facility,,,120,50.4,30.54,115.2,,102,,,percent of total billed charges,,,32.4,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,80.76,,,percent of total billed charges,,,101.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,104.4,,,percent of total billed charges,,,104.4,,,percent of total billed charges,,,102,,,percent of total billed charges,,,115.2,,,percent of total billed charges,,,114,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",108,,,percent of total billed charges,,,35.09,,,fee schedule,,,111.6,,,percent of total billed charges,,,114,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",93.72,,,percent of total billed charges,,,109.2,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HSV PRB AMP NS,3087467,CDM,306,RC,87529,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HSV PRB AMP NS,3087467,CDM,306,RC,87529,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HOMOGENIZATION TISSUE,3087491,CDM,306,RC,87176,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HOMOGENIZATION TISSUE,3087491,CDM,306,RC,87176,CPT,,,,,,outpatient,facility,,,52,21.84,5.12,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,5.88,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,5.88,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,8.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.94,,,fee schedule,,,5.22,,,fee schedule,,,5.22,,,fee schedule,,,5.12,,,fee schedule,,,5.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.88,,,fee schedule,,,5.88,,,fee schedule,,,7.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF ADENOVIRUS,3087517,CDM,306,RC,87260,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF ADENOVIRUS,3087517,CDM,306,RC,87260,CPT,,,,,,outpatient,facility,,,44,18.48,11.88,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.43,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.43,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,20.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.48,,,fee schedule,,,12.81,,,fee schedule,,,12.81,,,fee schedule,,,12.55,,,fee schedule,,,14.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.43,,,fee schedule,,,14.43,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF BORDETELLA,3087533,CDM,306,RC,87265,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF BORDETELLA,3087533,CDM,306,RC,87265,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.98,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF CRYPTOSPORIDIUM,3087566,CDM,306,RC,87272,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF CRYPTOSPORIDIUM,3087566,CDM,306,RC,87272,CPT,,,,,,outpatient,facility,,,61,25.62,10.43,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,11.98,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,11.98,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF HSV TYPE 1,3087582,CDM,306,RC,87274,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF HSV TYPE 1,3087582,CDM,306,RC,87274,CPT,,,,,,outpatient,facility,,,60,25.2,10.43,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,11.98,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,11.98,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF HSV TYPE 2,3087590,CDM,306,RC,87273,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF HSV TYPE 2,3087590,CDM,306,RC,87273,CPT,,,,,,outpatient,facility,,,60,25.2,10.43,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,11.98,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,11.98,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF INFLUENZA A VIRUS,3087608,CDM,306,RC,87276,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF INFLUENZA A VIRUS,3087608,CDM,306,RC,87276,CPT,,,,,,outpatient,facility,,,60,25.2,13.98,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,16.07,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,16.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,16.07,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,23.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.69,,,fee schedule,,,14.27,,,fee schedule,,,14.27,,,fee schedule,,,13.98,,,fee schedule,,,16.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,16.07,,,fee schedule,,,16.07,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF INFLUENZA B VIRUS,3087616,CDM,306,RC,87275,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF INFLUENZA B VIRUS,3087616,CDM,306,RC,87275,CPT,,,,,,outpatient,facility,,,60,25.2,10.66,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,12.25,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,12.25,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.54,,,fee schedule,,,10.88,,,fee schedule,,,10.88,,,fee schedule,,,10.66,,,fee schedule,,,12.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,12.25,,,fee schedule,,,12.25,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF PARAINFLUENZA,3087632,CDM,306,RC,87279,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF PARAINFLUENZA,3087632,CDM,306,RC,87279,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.43,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.43,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.18,,,fee schedule,,,14.59,,,fee schedule,,,14.59,,,fee schedule,,,14.3,,,fee schedule,,,16.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.43,,,fee schedule,,,16.43,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF PNEUMOCYSTIS,3087640,CDM,306,RC,87281,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF PNEUMOCYSTIS,3087640,CDM,306,RC,87281,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.98,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF PLYVLT ORG MULT,3087657,CDM,306,RC,87300,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF PLYVLT ORG MULT,3087657,CDM,306,RC,87300,CPT,,,,,,outpatient,facility,,,60,25.2,10.43,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,11.98,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,11.98,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF RSV,3087665,CDM,306,RC,87280,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF RSV,3087665,CDM,306,RC,87280,CPT,,,,,,outpatient,facility,,,60,25.2,11.68,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,13.42,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,13.42,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,19.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.12,,,fee schedule,,,11.92,,,fee schedule,,,11.92,,,fee schedule,,,11.68,,,fee schedule,,,13.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,13.42,,,fee schedule,,,13.42,,,fee schedule,,,31.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF VARICELLA ZOSTER,3087673,CDM,306,RC,87290,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF VARICELLA ZOSTER,3087673,CDM,306,RC,87290,CPT,,,,,,outpatient,facility,,,60,25.2,11.68,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,13.42,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,13.42,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,19.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.12,,,fee schedule,,,11.92,,,fee schedule,,,11.92,,,fee schedule,,,11.68,,,fee schedule,,,13.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,13.42,,,fee schedule,,,13.42,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM OPTICAL,3087681,CDM,306,RC,87899,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM OPTICAL,3087681,CDM,306,RC,87899,CPT,,,,,,outpatient,facility,,,65,27.3,13.98,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,16.07,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,16.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,16.07,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,23.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.69,,,fee schedule,,,14.27,,,fee schedule,,,14.27,,,fee schedule,,,13.98,,,fee schedule,,,16.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,16.07,,,fee schedule,,,16.07,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA INFLUENZA IMM OPT,3087715,CDM,306,RC,87804,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA INFLUENZA IMM OPT,3087715,CDM,306,RC,87804,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.55,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.55,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.34,,,fee schedule,,,14.7,,,fee schedule,,,14.7,,,fee schedule,,,14.41,,,fee schedule,,,16.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,14.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA MYCOBCT TB PRB AMP NS,3087749,CDM,306,RC,87556,CPT,,,,,,inpatient,facility,,,126,52.92,107.1,120.96,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.62,,,percent of total billed charges,,,,,,,,,113.4,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MYCOBCT TB PRB AMP NS,3087749,CDM,306,RC,87556,CPT,,,,,,outpatient,facility,,,126,52.92,34.02,120.96,,107.1,,,percent of total billed charges,,,34.02,,,percent of total billed charges,,,86.69,,,percent of total billed charges,,,84.8,,,percent of total billed charges,,,106.47,,,percent of total billed charges,,,41.68,,,fee schedule,,,109.62,,,percent of total billed charges,,,109.62,,,percent of total billed charges,,,107.1,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,42.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",113.4,,,percent of total billed charges,,,41.68,,,fee schedule,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,60.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.27,,,fee schedule,,,37.01,,,fee schedule,,,37.01,,,fee schedule,,,36.27,,,fee schedule,,,41.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",98.41,,,percent of total billed charges,,,114.66,,,percent of total billed charges,,,41.68,,,fee schedule,,,41.68,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB EXAM MACROSCOPIC ARTHROPOD,3087764,CDM,306,RC,87168,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB EXAM MACROSCOPIC ARTHROPOD,3087764,CDM,306,RC,87168,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.27,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.27,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB EXAM MACROSCOPIC PARASITE,3087772,CDM,306,RC,87169,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB EXAM MACROSCOPIC PARASITE,3087772,CDM,306,RC,87169,CPT,,,,,,outpatient,facility,,,58,24.36,3.75,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,4.31,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,4.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,4.31,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,6.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.82,,,fee schedule,,,3.83,,,fee schedule,,,3.83,,,fee schedule,,,3.75,,,fee schedule,,,4.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,4.31,,,fee schedule,,,4.31,,,fee schedule,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA ORGANISMS MULT PRB AMP,3087798,CDM,306,RC,87801,CPT,,,,,,inpatient,facility,,,211,88.62,179.35,202.56,,179.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.57,,,percent of total billed charges,,,,,,,,,189.9,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA ORGANISMS MULT PRB AMP,3087798,CDM,306,RC,87801,CPT,,,,,,outpatient,facility,,,211,88.62,56.97,202.56,,179.35,,,percent of total billed charges,,,56.97,,,percent of total billed charges,,,145.17,,,percent of total billed charges,,,142,,,percent of total billed charges,,,178.29,,,percent of total billed charges,,,70.2,,,fee schedule,,,183.57,,,percent of total billed charges,,,183.57,,,percent of total billed charges,,,179.35,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,71.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",189.9,,,percent of total billed charges,,,70.2,,,fee schedule,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,101.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",94.77,,,fee schedule,,,62.34,,,fee schedule,,,62.34,,,fee schedule,,,61.09,,,fee schedule,,,70.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",164.79,,,percent of total billed charges,,,192.01,,,percent of total billed charges,,,70.2,,,fee schedule,,,70.2,,,fee schedule,,,86.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA MYCOPLAS PNEU PRB AMP NS,3087806,CDM,306,RC,87581,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MYCOPLAS PNEU PRB AMP NS,3087806,CDM,306,RC,87581,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB EXAM PINWORM,3087822,CDM,306,RC,87172,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB EXAM PINWORM,3087822,CDM,306,RC,87172,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.27,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.27,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR INCL BODIES PARASITE,3087830,CDM,306,RC,87207,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR INCL BODIES PARASITE,3087830,CDM,306,RC,87207,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.99,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,6.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.99,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.09,,,fee schedule,,,5.32,,,fee schedule,,,5.32,,,fee schedule,,,5.21,,,fee schedule,,,5.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.99,,,fee schedule,,,5.99,,,fee schedule,,,5.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR STAIN ACID FAST AFB,3087848,CDM,306,RC,87206,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR STAIN ACID FAST AFB,3087848,CDM,306,RC,87206,CPT,,,,,,outpatient,facility,,,58,24.36,3.01,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,5.39,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,5.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,5.39,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,7.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.28,,,fee schedule,,,4.79,,,fee schedule,,,4.79,,,fee schedule,,,4.69,,,fee schedule,,,5.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,5.39,,,fee schedule,,,5.39,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR STAIN FL AFB,3087863,CDM,306,RC,87206,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR STAIN FL AFB,3087863,CDM,306,RC,87206,CPT,,,,,,outpatient,facility,,,57,23.94,3.01,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,5.39,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,5.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,5.39,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,7.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.28,,,fee schedule,,,4.79,,,fee schedule,,,4.79,,,fee schedule,,,4.69,,,fee schedule,,,5.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,5.39,,,fee schedule,,,5.39,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR STAIN FL FUNGI,3087889,CDM,306,RC,87206,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR STAIN FL FUNGI,3087889,CDM,306,RC,87206,CPT,,,,,,outpatient,facility,,,58,24.36,3.01,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,5.39,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,5.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,5.39,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,7.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.28,,,fee schedule,,,4.79,,,fee schedule,,,4.79,,,fee schedule,,,4.69,,,fee schedule,,,5.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,5.39,,,fee schedule,,,5.39,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR GRAM GIEMSA,3087897,CDM,306,RC,87205,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR GRAM GIEMSA,3087897,CDM,306,RC,87205,CPT,,,,,,outpatient,facility,,,13,5.46,3.01,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.27,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.27,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR IA INDIA INK,3087905,CDM,306,RC,87210,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR IA INDIA INK,3087905,CDM,306,RC,87210,CPT,,,,,,outpatient,facility,,,18,7.56,4.03,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.82,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.82,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.86,,,fee schedule,,,5.17,,,fee schedule,,,5.17,,,fee schedule,,,5.07,,,fee schedule,,,5.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.82,,,fee schedule,,,5.82,,,fee schedule,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEARS DIRECT OVA ANDPARASITES,3087913,CDM,306,RC,87177,CPT,,,,,,inpatient,facility,,,27,11.34,22.95,25.92,,22.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,23.49,,,percent of total billed charges,,,,,,,,,24.3,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25.11,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEARS DIRECT OVA ANDPARASITES,3087913,CDM,306,RC,87177,CPT,,,,,,outpatient,facility,,,27,11.34,7.29,25.92,,22.95,,,percent of total billed charges,,,7.29,,,percent of total billed charges,,,18.58,,,percent of total billed charges,,,18.17,,,percent of total billed charges,,,22.81,,,percent of total billed charges,,,8.9,,,fee schedule,,,23.49,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,9.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.3,,,percent of total billed charges,,,8.9,,,fee schedule,,,25.11,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,12.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.02,,,fee schedule,,,7.9,,,fee schedule,,,7.9,,,fee schedule,,,7.74,,,fee schedule,,,8.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",21.09,,,percent of total billed charges,,,24.57,,,percent of total billed charges,,,8.9,,,fee schedule,,,8.9,,,fee schedule,,,8.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT DISK KIRBY BAUER,3087947,CDM,306,RC,87184,CPT,,,,,,inpatient,facility,,,23,9.66,19.55,22.08,,19.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.01,,,percent of total billed charges,,,,,,,,,20.7,,,percent of total billed charges,,,22.08,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21.39,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT DISK KIRBY BAUER,3087947,CDM,306,RC,87184,CPT,,,,,,outpatient,facility,,,23,9.66,6.21,22.08,,19.55,,,percent of total billed charges,,,6.21,,,percent of total billed charges,,,15.82,,,percent of total billed charges,,,15.48,,,percent of total billed charges,,,19.43,,,percent of total billed charges,,,7.48,,,fee schedule,,,20.01,,,percent of total billed charges,,,20.01,,,percent of total billed charges,,,19.55,,,percent of total billed charges,,,22.08,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,7.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.7,,,percent of total billed charges,,,7.48,,,fee schedule,,,21.39,,,percent of total billed charges,,,21.85,,,percent of total billed charges,,,10.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.1,,,fee schedule,,,6.64,,,fee schedule,,,6.64,,,fee schedule,,,6.51,,,fee schedule,,,7.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",17.96,,,percent of total billed charges,,,20.93,,,percent of total billed charges,,,7.48,,,fee schedule,,,7.48,,,fee schedule,,,8.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT DETECTION ENZYME EA,3087954,CDM,306,RC,87185,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT DETECTION ENZYME EA,3087954,CDM,306,RC,87185,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.75,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.75,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.41,,,fee schedule,,,4.22,,,fee schedule,,,4.22,,,fee schedule,,,4.14,,,fee schedule,,,4.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.75,,,fee schedule,,,4.75,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT ETEST AGENT EA,3087962,CDM,306,RC,87181,CPT,,,,,,inpatient,facility,,,255,107.1,216.75,244.8,,216.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.85,,,percent of total billed charges,,,,,,,,,229.5,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.15,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT ETEST AGENT EA,3087962,CDM,306,RC,87181,CPT,,,,,,outpatient,facility,,,255,107.1,4.14,244.8,,216.75,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,175.44,,,percent of total billed charges,,,171.61,,,percent of total billed charges,,,215.47,,,percent of total billed charges,,,4.75,,,fee schedule,,,221.85,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,,216.75,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",229.5,,,percent of total billed charges,,,4.75,,,fee schedule,,,237.15,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,6.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.41,,,fee schedule,,,4.22,,,fee schedule,,,4.22,,,fee schedule,,,4.14,,,fee schedule,,,4.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",199.16,,,percent of total billed charges,,,232.05,,,percent of total billed charges,,,4.75,,,fee schedule,,,4.75,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT DILUTION MACROBROTH,3087970,CDM,306,RC,87188,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT DILUTION MACROBROTH,3087970,CDM,306,RC,87188,CPT,,,,,,outpatient,facility,,,58,24.36,5.78,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,6.64,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,6.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,6.64,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.96,,,fee schedule,,,5.9,,,fee schedule,,,5.9,,,fee schedule,,,5.78,,,fee schedule,,,6.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,6.64,,,fee schedule,,,6.64,,,fee schedule,,,8.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT MIC PLATE EA,3087988,CDM,306,RC,87186,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT MIC PLATE EA,3087988,CDM,306,RC,87186,CPT,,,,,,outpatient,facility,,,26,10.92,7.02,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.65,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.65,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.68,,,fee schedule,,,7.68,,,fee schedule,,,7.68,,,fee schedule,,,7.53,,,fee schedule,,,8.65,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.65,,,fee schedule,,,8.65,,,fee schedule,,,10.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TISSUE KOH SKIN HAIR NAIL FUNGI,3088002,CDM,306,RC,87220,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TISSUE KOH SKIN HAIR NAIL FUNGI,3088002,CDM,306,RC,87220,CPT,,,,,,outpatient,facility,,,64,26.88,3.71,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,4.27,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,4.27,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,16.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TOXIN CULT TISSUE C DIFF NS,3088010,CDM,306,RC,87230,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TOXIN CULT TISSUE C DIFF NS,3088010,CDM,306,RC,87230,CPT,,,,,,outpatient,facility,,,79,33.18,17.18,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,19.74,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,20.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,19.74,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,28.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.65,,,fee schedule,,,17.53,,,fee schedule,,,17.53,,,fee schedule,,,17.18,,,fee schedule,,,19.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,19.74,,,fee schedule,,,19.74,,,fee schedule,,,24.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR GRAM GIEMSA URINE EOSNPHL,3088028,CDM,306,RC,87205,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR GRAM GIEMSA URINE EOSNPHL,3088028,CDM,306,RC,87205,CPT,,,,,,outpatient,facility,,,13,5.46,3.01,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.27,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.27,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR IA WET MOUNT,3088036,CDM,306,RC,87210,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR IA WET MOUNT,3088036,CDM,306,RC,87210,CPT,,,,,,outpatient,facility,,,53,22.26,4.03,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,5.82,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,5.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,5.82,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,8.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.86,,,fee schedule,,,5.17,,,fee schedule,,,5.17,,,fee schedule,,,5.07,,,fee schedule,,,5.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,5.82,,,fee schedule,,,5.82,,,fee schedule,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA REDUCING SUBSTANCE,3088069,CDM,307,RC,81002,CPT,,,,,,inpatient,facility,,,11,4.62,9.35,10.56,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA REDUCING SUBSTANCE,3088069,CDM,307,RC,81002,CPT,,,,,,outpatient,facility,,,11,4.62,2.52,10.56,,9.35,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,3.48,,,fee schedule,,,9.57,,,percent of total billed charges,,,9.57,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,3.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.9,,,percent of total billed charges,,,3.48,,,fee schedule,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,5.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.7,,,fee schedule,,,3.09,,,fee schedule,,,3.09,,,fee schedule,,,3.03,,,fee schedule,,,3.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",8.59,,,percent of total billed charges,,,10.01,,,percent of total billed charges,,,3.48,,,fee schedule,,,3.48,,,fee schedule,,,2.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA KETONES AUTO WO MICRO,3088085,CDM,307,RC,81003,CPT,,,,,,inpatient,facility,,,7,2.94,5.95,6.72,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.09,,,percent of total billed charges,,,,,,,,,6.3,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA KETONES AUTO WO MICRO,3088085,CDM,307,RC,81003,CPT,,,,,,outpatient,facility,,,7,2.94,1.89,6.72,,5.95,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.09,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,5.95,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,2.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.3,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,3.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.04,,,fee schedule,,,2,,,fee schedule,,,2,,,fee schedule,,,1.96,,,fee schedule,,,2.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",5.47,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,2.25,,,fee schedule,,,2.25,,,fee schedule,,,2.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA PH AUTO WO MICRO,3088093,CDM,307,RC,81003,CPT,,,,,,inpatient,facility,,,7,2.94,5.95,6.72,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.09,,,percent of total billed charges,,,,,,,,,6.3,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA PH AUTO WO MICRO,3088093,CDM,307,RC,81003,CPT,,,,,,outpatient,facility,,,7,2.94,1.89,6.72,,5.95,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.09,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,5.95,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,2.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.3,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,3.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.04,,,fee schedule,,,2,,,fee schedule,,,2,,,fee schedule,,,1.96,,,fee schedule,,,2.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",5.47,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,2.25,,,fee schedule,,,2.25,,,fee schedule,,,2.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA GRAVITY SPCFC AUTO WO MICRO,3088101,CDM,307,RC,81003,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA GRAVITY SPCFC AUTO WO MICRO,3088101,CDM,307,RC,81003,CPT,,,,,,outpatient,facility,,,53,22.26,1.96,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,2.25,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,2.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,2.25,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,3.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.04,,,fee schedule,,,2,,,fee schedule,,,2,,,fee schedule,,,1.96,,,fee schedule,,,2.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,2.25,,,fee schedule,,,2.25,,,fee schedule,,,2.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA AUTO W MICRO,3088119,CDM,307,RC,81001,CPT,,,,,,inpatient,facility,,,10,4.2,8.5,9.6,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,,percent of total billed charges,,,,,,,,,9,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA AUTO W MICRO,3088119,CDM,307,RC,81001,CPT,,,,,,outpatient,facility,,,10,4.2,2.7,9.6,,8.5,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,3.17,,,fee schedule,,,8.7,,,percent of total billed charges,,,8.7,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,3.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9,,,percent of total billed charges,,,3.17,,,fee schedule,,,9.3,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,4.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.28,,,fee schedule,,,2.81,,,fee schedule,,,2.81,,,fee schedule,,,2.75,,,fee schedule,,,3.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",7.81,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,3.17,,,fee schedule,,,3.17,,,fee schedule,,,3.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA AUTO WO MICRO,3088127,CDM,307,RC,81003,CPT,,,,,,inpatient,facility,,,7,2.94,5.95,6.72,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.09,,,percent of total billed charges,,,,,,,,,6.3,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA AUTO WO MICRO,3088127,CDM,307,RC,81003,CPT,,,,,,outpatient,facility,,,7,2.94,1.89,6.72,,5.95,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.09,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,5.95,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,2.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.3,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,3.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.04,,,fee schedule,,,2,,,fee schedule,,,2,,,fee schedule,,,1.96,,,fee schedule,,,2.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",5.47,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,2.25,,,fee schedule,,,2.25,,,fee schedule,,,2.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA MICROSCOPIC ONLY,3088135,CDM,307,RC,81015,CPT,,,,,,inpatient,facility,,,10,4.2,8.5,9.6,,8.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8.7,,,percent of total billed charges,,,,,,,,,9,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9.3,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA MICROSCOPIC ONLY,3088135,CDM,307,RC,81015,CPT,,,,,,outpatient,facility,,,10,4.2,2.06,9.6,,8.5,,,percent of total billed charges,,,2.7,,,percent of total billed charges,,,6.88,,,percent of total billed charges,,,6.73,,,percent of total billed charges,,,8.45,,,percent of total billed charges,,,3.05,,,fee schedule,,,8.7,,,percent of total billed charges,,,8.7,,,percent of total billed charges,,,8.5,,,percent of total billed charges,,,9.6,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,3.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9,,,percent of total billed charges,,,3.05,,,fee schedule,,,9.3,,,percent of total billed charges,,,9.5,,,percent of total billed charges,,,4.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.12,,,fee schedule,,,2.71,,,fee schedule,,,2.71,,,fee schedule,,,2.66,,,fee schedule,,,3.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",7.81,,,percent of total billed charges,,,9.1,,,percent of total billed charges,,,3.05,,,fee schedule,,,3.05,,,fee schedule,,,2.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA NONAUTO WO MICRO,3088143,CDM,307,RC,81002,CPT,,,,,,inpatient,facility,,,11,4.62,9.35,10.56,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA NONAUTO WO MICRO,3088143,CDM,307,RC,81002,CPT,,,,,,outpatient,facility,,,11,4.62,2.52,10.56,,9.35,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,3.48,,,fee schedule,,,9.57,,,percent of total billed charges,,,9.57,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,3.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.9,,,percent of total billed charges,,,3.48,,,fee schedule,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,5.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.7,,,fee schedule,,,3.09,,,fee schedule,,,3.09,,,fee schedule,,,3.03,,,fee schedule,,,3.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",8.59,,,percent of total billed charges,,,10.01,,,percent of total billed charges,,,3.48,,,fee schedule,,,3.48,,,fee schedule,,,2.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB UA QL SEMI QN,3088168,CDM,307,RC,81005,CPT,,,,,,inpatient,facility,,,7,2.94,5.95,6.72,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.09,,,percent of total billed charges,,,,,,,,,6.3,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB UA QL SEMI QN,3088168,CDM,307,RC,81005,CPT,,,,,,outpatient,facility,,,7,2.94,1.89,6.72,,5.95,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,2.17,,,fee schedule,,,6.09,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,5.95,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,2.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.3,,,percent of total billed charges,,,2.17,,,fee schedule,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,3.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2.93,,,fee schedule,,,1.93,,,fee schedule,,,1.93,,,fee schedule,,,1.89,,,fee schedule,,,2.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",5.47,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,2.17,,,fee schedule,,,2.17,,,fee schedule,,,2.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PREGNANCY URINE,3088192,CDM,307,RC,81025,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PREGNANCY URINE,3088192,CDM,307,RC,81025,CPT,,,,,,outpatient,facility,,,58,24.36,7.5,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,8.61,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,8.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,8.61,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,12.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.62,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,8.61,,,fee schedule,,,8.61,,,fee schedule,,,8.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MEASUREMENT VOL COLL TIMED EA,3088200,CDM,307,RC,81050,CPT,,,,,,inpatient,facility,,,11,4.62,9.35,10.56,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MEASUREMENT VOL COLL TIMED EA,3088200,CDM,307,RC,81050,CPT,,,,,,outpatient,facility,,,11,4.62,2.09,10.56,,9.35,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,3.64,,,fee schedule,,,9.57,,,percent of total billed charges,,,9.57,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,3.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.9,,,percent of total billed charges,,,3.64,,,fee schedule,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.91,,,fee schedule,,,3.23,,,fee schedule,,,3.23,,,fee schedule,,,3.17,,,fee schedule,,,3.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",8.59,,,percent of total billed charges,,,10.01,,,percent of total billed charges,,,3.64,,,fee schedule,,,3.64,,,fee schedule,,,2.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
COLLECT SPEC BLD CAPILLARY,3088226,CDM,300,RC,36416,CPT,,,,,,inpatient,facility,,,34,14.28,28.9,32.64,,28.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29.58,,,percent of total billed charges,,,,,,,,,30.6,,,percent of total billed charges,,,32.64,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31.62,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
COLLECT SPEC BLD CAPILLARY,3088226,CDM,300,RC,36416,CPT,,,,,,outpatient,facility,,,34,14.28,9.18,34,,28.9,,,percent of total billed charges,,,9.18,,,percent of total billed charges,,,23.39,,,percent of total billed charges,,,22.88,,,percent of total billed charges,,,28.73,,,percent of total billed charges,,,,,,,,,29.58,,,percent of total billed charges,,,29.58,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,32.64,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,,,,,,,30.6,,,percent of total billed charges,,,,,,,,,31.62,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,34,,,fee schedule,,,34,,,fee schedule,,,34,,,fee schedule,,,,,,,,,26.55,,,percent of total billed charges,,,30.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PROT FRCTN ELECTRO ANDQN URINE,3088283,CDM,301,RC,84166,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT FRCTN ELECTRO ANDQN URINE,3088283,CDM,301,RC,84166,CPT,,,,,,outpatient,facility,,,54,22.68,14.58,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,17.83,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,18.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,17.83,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,25.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.07,,,fee schedule,,,15.83,,,fee schedule,,,15.83,,,fee schedule,,,15.51,,,fee schedule,,,17.83,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,17.83,,,fee schedule,,,17.83,,,fee schedule,,,19.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALPHA 1 ANTITRYPSIN TOTAL,3088861,CDM,301,RC,82103,CPT,,,,,,inpatient,facility,,,41,17.22,34.85,39.36,,34.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35.67,,,percent of total billed charges,,,,,,,,,36.9,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALPHA 1 ANTITRYPSIN TOTAL,3088861,CDM,301,RC,82103,CPT,,,,,,outpatient,facility,,,41,17.22,11.07,39.36,,34.85,,,percent of total billed charges,,,11.07,,,percent of total billed charges,,,28.21,,,percent of total billed charges,,,27.59,,,percent of total billed charges,,,34.64,,,percent of total billed charges,,,13.44,,,fee schedule,,,35.67,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,34.85,,,percent of total billed charges,,,39.36,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,13.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.9,,,percent of total billed charges,,,13.44,,,fee schedule,,,38.13,,,percent of total billed charges,,,38.95,,,percent of total billed charges,,,19.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.14,,,fee schedule,,,11.93,,,fee schedule,,,11.93,,,fee schedule,,,11.69,,,fee schedule,,,13.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.02,,,percent of total billed charges,,,37.31,,,percent of total billed charges,,,13.44,,,fee schedule,,,13.44,,,fee schedule,,,16.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC UA NONAUTO WO MICRO DIPSTICK,3088879,CDM,307,RC,81002,CPT,,,,,,inpatient,facility,,,11,4.62,9.35,10.56,,9.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9.57,,,percent of total billed charges,,,,,,,,,9.9,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC UA NONAUTO WO MICRO DIPSTICK,3088879,CDM,307,RC,81002,CPT,,,,,,outpatient,facility,,,11,4.62,2.52,10.56,,9.35,,,percent of total billed charges,,,2.97,,,percent of total billed charges,,,7.57,,,percent of total billed charges,,,7.4,,,percent of total billed charges,,,9.29,,,percent of total billed charges,,,3.48,,,fee schedule,,,9.57,,,percent of total billed charges,,,9.57,,,percent of total billed charges,,,9.35,,,percent of total billed charges,,,10.56,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,3.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.9,,,percent of total billed charges,,,3.48,,,fee schedule,,,10.23,,,percent of total billed charges,,,10.45,,,percent of total billed charges,,,5.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.7,,,fee schedule,,,3.09,,,fee schedule,,,3.09,,,fee schedule,,,3.03,,,fee schedule,,,3.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",8.59,,,percent of total billed charges,,,10.01,,,percent of total billed charges,,,3.48,,,fee schedule,,,3.48,,,fee schedule,,,2.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB STAIN SPECIAL 2 NS,3088937,CDM,312,RC,88313,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB STAIN SPECIAL 2 NS,3088937,CDM,312,RC,88313,CPT,,,,,,outpatient,facility,,,102,42.84,27.54,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,61.17,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB STAIN SPECIAL 2 NS,3088937,CDM,312,RC,88313,CPT,5733,APC,,,,outpatient,facility,,,102,102,31.22,90.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,90.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,62.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,31.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONSULT SLIDES REFERRED NS,3088945,CDM,312,RC,88321,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT SLIDES REFERRED NS,3088945,CDM,312,RC,88321,CPT,,,,,,outpatient,facility,,,102,42.84,27.54,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,,,,,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,40.1,,,fee schedule,,,,,,,,,79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT SLIDES REFERRED NS,3088945,CDM,312,RC,88321,CPT,5732,APC,,,,outpatient,facility,,,102,102,18.45,59.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,59.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,18.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MICROSCOPY ELECTRON DIAG NS,3088978,CDM,312,RC,88348,CPT,,,,,,inpatient,facility,,,2330,978.6,1980.5,2236.8,,1980.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.1,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MICROSCOPY ELECTRON DIAG NS,3088978,CDM,312,RC,88348,CPT,,,,,,outpatient,facility,,,2330,978.6,629.1,2236.8,,1980.5,,,percent of total billed charges,,,629.1,,,percent of total billed charges,,,1603.04,,,percent of total billed charges,,,1568.09,,,percent of total billed charges,,,1968.85,,,percent of total billed charges,,,,,,,,,2027.1,,,percent of total billed charges,,,2027.1,,,percent of total billed charges,,,1980.5,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,859.91,,,fee schedule,,,,,,,,,1819.73,,,percent of total billed charges,,,2120.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MICROSCOPY ELECTRON DIAG NS,3088978,CDM,312,RC,88348,CPT,5674,APC,,,,outpatient,facility,,,2330,2330,421.8,1272.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,895.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,1272.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1184.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,877.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,421.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB AGG PARTICLE EA,3089000,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB AGG PARTICLE EA,3089000,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,74,31.08,10.05,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,11.54,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,11.54,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF GIARDIA,3094034,CDM,306,RC,87269,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF GIARDIA,3094034,CDM,306,RC,87269,CPT,,,,,,outpatient,facility,,,61,25.62,11.85,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,13.61,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,13.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,13.61,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,19.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.37,,,fee schedule,,,12.09,,,fee schedule,,,12.09,,,fee schedule,,,11.85,,,fee schedule,,,13.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,13.61,,,fee schedule,,,13.61,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ GIARDIA NS,3094042,CDM,306,RC,87329,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ GIARDIA NS,3094042,CDM,306,RC,87329,CPT,,,,,,outpatient,facility,,,66,27.72,10.43,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,11.98,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC COLLECT SPEC SPUTUM AEROSOL,3094059,CDM,300,RC,89220,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC COLLECT SPEC SPUTUM AEROSOL,3094059,CDM,300,RC,89220,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
POC COLLECT SPEC SPUTUM AEROSOL,3094059,CDM,300,RC,89220,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR STAIN CMPLX OVA ANDPARASITES,3094091,CDM,306,RC,87209,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR STAIN CMPLX OVA ANDPARASITES,3094091,CDM,306,RC,87209,CPT,,,,,,outpatient,facility,,,54,22.68,14.58,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,17.98,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,18.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,17.98,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,26.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.27,,,fee schedule,,,15.97,,,fee schedule,,,15.97,,,fee schedule,,,15.65,,,fee schedule,,,17.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,17.98,,,fee schedule,,,17.98,,,fee schedule,,,16.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT ANAEROBIC OTHER QN,3094109,CDM,306,RC,87073,CPT,,,,,,inpatient,facility,,,29,12.18,24.65,27.84,,24.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25.23,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT ANAEROBIC OTHER QN,3094109,CDM,306,RC,87073,CPT,,,,,,outpatient,facility,,,29,12.18,4.6,27.84,,24.65,,,percent of total billed charges,,,7.83,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,19.52,,,percent of total billed charges,,,24.5,,,percent of total billed charges,,,9.66,,,fee schedule,,,25.23,,,percent of total billed charges,,,25.23,,,percent of total billed charges,,,24.65,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,9.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.1,,,percent of total billed charges,,,9.66,,,fee schedule,,,26.97,,,percent of total billed charges,,,27.55,,,percent of total billed charges,,,14.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.04,,,fee schedule,,,8.58,,,fee schedule,,,8.58,,,fee schedule,,,8.41,,,fee schedule,,,9.66,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",22.65,,,percent of total billed charges,,,26.39,,,percent of total billed charges,,,9.66,,,fee schedule,,,9.66,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT STREP GROUP A,3094125,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT STREP GROUP A,3094125,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,20,8.4,5.16,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.63,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.63,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC COUNT BLD HEMATOCRIT,3094166,CDM,305,RC,85014,CPT,,,,,,inpatient,facility,,,8,3.36,6.8,7.68,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC COUNT BLD HEMATOCRIT,3094166,CDM,305,RC,85014,CPT,,,,,,outpatient,facility,,,8,3.36,2.06,7.68,,6.8,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,2.37,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.2,,,percent of total billed charges,,,2.37,,,fee schedule,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,2.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC COUNT BLD HEMOGLOBIN,3094174,CDM,305,RC,85018,CPT,,,,,,inpatient,facility,,,8,3.36,6.8,7.68,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC COUNT BLD HEMOGLOBIN,3094174,CDM,305,RC,85018,CPT,,,,,,outpatient,facility,,,8,3.36,1.95,7.68,,6.8,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,2.37,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.2,,,percent of total billed charges,,,2.37,,,fee schedule,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,1.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AGGREGATION PLT EA AGENT,3094182,CDM,305,RC,85576,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AGGREGATION PLT EA AGENT,3094182,CDM,305,RC,85576,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,24.91,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,25.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,24.91,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,36.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.63,,,fee schedule,,,22.12,,,fee schedule,,,22.12,,,fee schedule,,,21.68,,,fee schedule,,,24.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,24.91,,,fee schedule,,,24.91,,,fee schedule,,,26.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PHLEBOTOMY THERAPEUTIC,3094265,CDM,940,RC,99195,CPT,,,,,,inpatient,facility,,,284,119.28,241.4,272.64,,241.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.08,,,percent of total billed charges,,,,,,,,,255.6,,,percent of total billed charges,,,272.64,,,percent of total billed charges,,,269.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,264.12,,,percent of total billed charges,,,269.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PHLEBOTOMY THERAPEUTIC,3094265,CDM,940,RC,99195,CPT,,,,,,outpatient,facility,,,284,119.28,76.68,272.64,,241.4,,,percent of total billed charges,,,76.68,,,percent of total billed charges,,,195.39,,,percent of total billed charges,,,191.13,,,percent of total billed charges,,,239.98,,,percent of total billed charges,,,,,,,,,247.08,,,percent of total billed charges,,,247.08,,,percent of total billed charges,,,241.4,,,percent of total billed charges,,,272.64,,,percent of total billed charges,,,269.8,,,percent of total billed charges,,,,,,,,,255.6,,,percent of total billed charges,,,,,,,,,264.12,,,percent of total billed charges,,,269.8,,,percent of total billed charges,,,,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,127.74,,,fee schedule,,,,,,,,,221.8,,,percent of total billed charges,,,258.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PHLEBOTOMY THERAPEUTIC,3094265,CDM,940,RC,99195,CPT,5734,APC,,,,outpatient,facility,,,284,284,63.07,189.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,189.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,130.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,63.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC COAGULATION TIME ACTIVATED,3094497,CDM,305,RC,85347,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC COAGULATION TIME ACTIVATED,3094497,CDM,305,RC,85347,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.28,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.28,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.78,,,fee schedule,,,3.8,,,fee schedule,,,3.8,,,fee schedule,,,3.72,,,fee schedule,,,4.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.28,,,fee schedule,,,4.28,,,fee schedule,,,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC PREGNANCY URINE,3094539,CDM,307,RC,81025,CPT,,,,,,inpatient,facility,,,26,10.92,22.1,24.96,,22.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22.62,,,percent of total billed charges,,,,,,,,,23.4,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC PREGNANCY URINE,3094539,CDM,307,RC,81025,CPT,,,,,,outpatient,facility,,,26,10.92,7.02,24.96,,22.1,,,percent of total billed charges,,,7.02,,,percent of total billed charges,,,17.89,,,percent of total billed charges,,,17.5,,,percent of total billed charges,,,21.97,,,percent of total billed charges,,,8.61,,,fee schedule,,,22.62,,,percent of total billed charges,,,22.62,,,percent of total billed charges,,,22.1,,,percent of total billed charges,,,24.96,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,8.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.4,,,percent of total billed charges,,,8.61,,,fee schedule,,,24.18,,,percent of total billed charges,,,24.7,,,percent of total billed charges,,,12.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.62,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",20.31,,,percent of total billed charges,,,23.66,,,percent of total billed charges,,,8.61,,,fee schedule,,,8.61,,,fee schedule,,,8.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC GASES BLD ANY COMBO,3094638,CDM,301,RC,82803,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GASES BLD ANY COMBO,3094638,CDM,301,RC,82803,CPT,,,,,,outpatient,facility,,,79,33.18,21.33,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,26.07,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,26.07,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,37.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.19,,,fee schedule,,,23.15,,,fee schedule,,,23.15,,,fee schedule,,,22.69,,,fee schedule,,,26.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,26.07,,,fee schedule,,,26.07,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LEVETIRACETAM NS,3094646,CDM,301,RC,80177,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LEVETIRACETAM NS,3094646,CDM,301,RC,80177,CPT,,,,,,outpatient,facility,,,63,26.46,11.53,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,13.25,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,13.25,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA STREP GROUP A PRB AMP,3094661,CDM,306,RC,87651,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA STREP GROUP A PRB AMP,3094661,CDM,306,RC,87651,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC BLOOD OCCULT FECES 1 3 TESTS QL,3094778,CDM,301,RC,82272,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC BLOOD OCCULT FECES 1 3 TESTS QL,3094778,CDM,301,RC,82272,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.23,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.23,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.71,,,fee schedule,,,3.76,,,fee schedule,,,3.76,,,fee schedule,,,3.68,,,fee schedule,,,4.23,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.23,,,fee schedule,,,4.23,,,fee schedule,,,3.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC SODIUM SRM PLASMA BLD WHL,3094786,CDM,301,RC,84295,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC SODIUM SRM PLASMA BLD WHL,3094786,CDM,301,RC,84295,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.81,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.81,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.49,,,fee schedule,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,4.18,,,fee schedule,,,4.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.81,,,fee schedule,,,4.81,,,fee schedule,,,5.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC POTASS SRM PLASMA BLD WHL,3094794,CDM,301,RC,84132,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC POTASS SRM PLASMA BLD WHL,3094794,CDM,301,RC,84132,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.76,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.76,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.43,,,fee schedule,,,4.23,,,fee schedule,,,4.23,,,fee schedule,,,4.15,,,fee schedule,,,4.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.76,,,fee schedule,,,4.76,,,fee schedule,,,5.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC NITROGEN UREA QN,3094802,CDM,301,RC,84520,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC NITROGEN UREA QN,3094802,CDM,301,RC,84520,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,11.52,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.95,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.95,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.33,,,fee schedule,,,3.51,,,fee schedule,,,3.51,,,fee schedule,,,3.44,,,fee schedule,,,3.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CHLORIDE BLOOD,3094810,CDM,301,RC,82435,CPT,,,,,,inpatient,facility,,,14,5.88,11.9,13.44,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CHLORIDE BLOOD,3094810,CDM,301,RC,82435,CPT,,,,,,outpatient,facility,,,14,5.88,3.78,13.44,,11.9,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.6,,,fee schedule,,,12.18,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,11.9,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,4.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.6,,,percent of total billed charges,,,4.6,,,fee schedule,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,6.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.21,,,fee schedule,,,4.08,,,fee schedule,,,4.08,,,fee schedule,,,4,,,fee schedule,,,4.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.93,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,5.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CULT BACT H PYLORI FAST,3094844,CDM,306,RC,87077,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CULT BACT H PYLORI FAST,3094844,CDM,306,RC,87077,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.08,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.08,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.91,,,fee schedule,,,7.18,,,fee schedule,,,7.18,,,fee schedule,,,7.04,,,fee schedule,,,8.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.08,,,fee schedule,,,8.08,,,fee schedule,,,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CALCIUM IONIZED,3094968,CDM,301,RC,82330,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CALCIUM IONIZED,3094968,CDM,301,RC,82330,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.68,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,13.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.68,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,19.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.47,,,fee schedule,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,11.91,,,fee schedule,,,13.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.68,,,fee schedule,,,13.68,,,fee schedule,,,16.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOP SLD LIQ NONGYN,3094976,CDM,311,RC,88112,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOP SLD LIQ NONGYN,3094976,CDM,311,RC,88112,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOP SLD LIQ NONGYN,3094976,CDM,311,RC,88112,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALKALINE PHOSPHATASE NS,3095015,CDM,301,RC,84075,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALKALINE PHOSPHATASE NS,3095015,CDM,301,RC,84075,CPT,,,,,,outpatient,facility,,,57,23.94,4.51,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,5.18,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,5.18,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT TOTAL CELLS CD56 NK,3095049,CDM,302,RC,86357,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT TOTAL CELLS CD56 NK,3095049,CDM,302,RC,86357,CPT,,,,,,outpatient,facility,,,114,47.88,30.78,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,37.73,,,fee schedule,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.6,,,percent of total billed charges,,,37.73,,,fee schedule,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,46.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB B CELLS CD19 COUNT TOTAL,3095056,CDM,302,RC,86355,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB B CELLS CD19 COUNT TOTAL,3095056,CDM,302,RC,86355,CPT,,,,,,outpatient,facility,,,114,47.88,30.78,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,37.73,,,fee schedule,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.6,,,percent of total billed charges,,,37.73,,,fee schedule,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,46.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOM FLOW TECH MARKER 1ST,3095064,CDM,311,RC,88184,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOM FLOW TECH MARKER 1ST,3095064,CDM,311,RC,88184,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOM FLOW TECH MARKER 1ST,3095064,CDM,311,RC,88184,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT FRCTN ELECTRO ANDQN OTHER,3095114,CDM,301,RC,84166,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT FRCTN ELECTRO ANDQN OTHER,3095114,CDM,301,RC,84166,CPT,,,,,,outpatient,facility,,,54,22.68,14.58,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,17.83,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,18.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,17.83,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,25.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.07,,,fee schedule,,,15.83,,,fee schedule,,,15.83,,,fee schedule,,,15.51,,,fee schedule,,,17.83,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,17.83,,,fee schedule,,,17.83,,,fee schedule,,,19.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT CELLS T CD4 ABSOLUTE,3095122,CDM,302,RC,86361,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELLS T CD4 ABSOLUTE,3095122,CDM,302,RC,86361,CPT,,,,,,outpatient,facility,,,111,46.62,22.18,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,26.78,,,fee schedule,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,27.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",99.9,,,percent of total billed charges,,,26.78,,,fee schedule,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,38.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.15,,,fee schedule,,,23.78,,,fee schedule,,,23.78,,,fee schedule,,,23.3,,,fee schedule,,,26.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,26.78,,,fee schedule,,,26.78,,,fee schedule,,,22.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOM FLOW TECH MARKER ADDL,3095130,CDM,311,RC,88185,CPT,,,,,,inpatient,facility,,,119,49.98,101.15,114.24,,101.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,103.53,,,percent of total billed charges,,,,,,,,,107.1,,,percent of total billed charges,,,114.24,,,percent of total billed charges,,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,110.67,,,percent of total billed charges,,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOM FLOW TECH MARKER ADDL,3095130,CDM,311,RC,88185,CPT,,,,,,outpatient,facility,,,119,49.98,32.13,119,,101.15,,,percent of total billed charges,,,32.13,,,percent of total billed charges,,,81.87,,,percent of total billed charges,,,80.09,,,percent of total billed charges,,,100.55,,,percent of total billed charges,,,,,,,,,103.53,,,percent of total billed charges,,,103.53,,,percent of total billed charges,,,101.15,,,percent of total billed charges,,,114.24,,,percent of total billed charges,,,113.05,,,percent of total billed charges,,,,,,,,,107.1,,,percent of total billed charges,,,,,,,,,110.67,,,percent of total billed charges,,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,,119,,,fee schedule,,,119,,,fee schedule,,,119,,,fee schedule,,,,,,,,,92.94,,,percent of total billed charges,,,108.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
POC PROTHROMBIN TIME,3095205,CDM,305,RC,85610,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC PROTHROMBIN TIME,3095205,CDM,305,RC,85610,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.29,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.29,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.79,,,fee schedule,,,3.81,,,fee schedule,,,3.81,,,fee schedule,,,3.73,,,fee schedule,,,4.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.29,,,fee schedule,,,4.29,,,fee schedule,,,3.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM W BND 15 20 CLL 2 KRTY NS,3102894,CDM,311,RC,88262,CPT,,,,,,inpatient,facility,,,377,158.34,320.45,361.92,,320.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.99,,,percent of total billed charges,,,,,,,,,339.3,,,percent of total billed charges,,,361.92,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,350.61,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM W BND 15 20 CLL 2 KRTY NS,3102894,CDM,311,RC,88262,CPT,,,,,,outpatient,facility,,,377,158.34,101.79,361.92,,320.45,,,percent of total billed charges,,,101.79,,,percent of total billed charges,,,259.38,,,percent of total billed charges,,,253.72,,,percent of total billed charges,,,318.56,,,percent of total billed charges,,,125.49,,,fee schedule,,,327.99,,,percent of total billed charges,,,327.99,,,percent of total billed charges,,,320.45,,,percent of total billed charges,,,361.92,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,128,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",339.3,,,percent of total billed charges,,,125.49,,,fee schedule,,,350.61,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,181.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",169.41,,,fee schedule,,,111.44,,,fee schedule,,,111.44,,,fee schedule,,,109.21,,,fee schedule,,,125.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",294.44,,,percent of total billed charges,,,343.07,,,percent of total billed charges,,,125.49,,,fee schedule,,,125.49,,,fee schedule,,,152.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM W BND 15 20 CLL 2 KRTY,3102902,CDM,311,RC,88262,CPT,,,,,,inpatient,facility,,,377,158.34,320.45,361.92,,320.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,327.99,,,percent of total billed charges,,,,,,,,,339.3,,,percent of total billed charges,,,361.92,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,350.61,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM W BND 15 20 CLL 2 KRTY,3102902,CDM,311,RC,88262,CPT,,,,,,outpatient,facility,,,377,158.34,101.79,361.92,,320.45,,,percent of total billed charges,,,101.79,,,percent of total billed charges,,,259.38,,,percent of total billed charges,,,253.72,,,percent of total billed charges,,,318.56,,,percent of total billed charges,,,125.49,,,fee schedule,,,327.99,,,percent of total billed charges,,,327.99,,,percent of total billed charges,,,320.45,,,percent of total billed charges,,,361.92,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,128,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",339.3,,,percent of total billed charges,,,125.49,,,fee schedule,,,350.61,,,percent of total billed charges,,,358.15,,,percent of total billed charges,,,181.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",169.41,,,fee schedule,,,111.44,,,fee schedule,,,111.44,,,fee schedule,,,109.21,,,fee schedule,,,125.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",294.44,,,percent of total billed charges,,,343.07,,,percent of total billed charges,,,125.49,,,fee schedule,,,125.49,,,fee schedule,,,152.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM W BND 45 CLL 2 KRTY,3102910,CDM,311,RC,88263,CPT,,,,,,inpatient,facility,,,451,189.42,383.35,432.96,,383.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.37,,,percent of total billed charges,,,,,,,,,405.9,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM W BND 45 CLL 2 KRTY,3102910,CDM,311,RC,88263,CPT,,,,,,outpatient,facility,,,451,189.42,121.77,432.96,,383.35,,,percent of total billed charges,,,121.77,,,percent of total billed charges,,,310.29,,,percent of total billed charges,,,303.52,,,percent of total billed charges,,,381.09,,,percent of total billed charges,,,150.29,,,fee schedule,,,392.37,,,percent of total billed charges,,,392.37,,,percent of total billed charges,,,383.35,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,153.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",405.9,,,percent of total billed charges,,,150.29,,,fee schedule,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,217.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",202.89,,,fee schedule,,,133.46,,,fee schedule,,,133.46,,,fee schedule,,,130.79,,,fee schedule,,,150.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",352.23,,,percent of total billed charges,,,410.41,,,percent of total billed charges,,,150.29,,,fee schedule,,,150.29,,,fee schedule,,,184.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM W BND AF 6 12 COL 1 K,3102928,CDM,311,RC,88269,CPT,,,,,,inpatient,facility,,,521,218.82,442.85,500.16,,442.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.27,,,percent of total billed charges,,,,,,,,,468.9,,,percent of total billed charges,,,500.16,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,484.53,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM W BND AF 6 12 COL 1 K,3102928,CDM,311,RC,88269,CPT,,,,,,outpatient,facility,,,521,218.82,140.67,500.16,,442.85,,,percent of total billed charges,,,140.67,,,percent of total billed charges,,,358.45,,,percent of total billed charges,,,350.63,,,percent of total billed charges,,,440.25,,,percent of total billed charges,,,173.66,,,fee schedule,,,453.27,,,percent of total billed charges,,,453.27,,,percent of total billed charges,,,442.85,,,percent of total billed charges,,,500.16,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,177.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",468.9,,,percent of total billed charges,,,173.66,,,fee schedule,,,484.53,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,251.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",234.44,,,fee schedule,,,154.21,,,fee schedule,,,154.21,,,fee schedule,,,151.13,,,fee schedule,,,173.66,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",406.9,,,percent of total billed charges,,,474.11,,,percent of total billed charges,,,173.66,,,fee schedule,,,173.66,,,fee schedule,,,203.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MCG IN SITU CHROM 10 30 CELL,3102936,CDM,311,RC,88273,CPT,,,,,,inpatient,facility,,,105,44.1,89.25,100.8,,89.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,91.35,,,percent of total billed charges,,,,,,,,,94.5,,,percent of total billed charges,,,100.8,,,percent of total billed charges,,,99.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,97.65,,,percent of total billed charges,,,99.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MCG IN SITU CHROM 10 30 CELL,3102936,CDM,311,RC,88273,CPT,,,,,,outpatient,facility,,,105,44.1,28.35,100.8,,89.25,,,percent of total billed charges,,,28.35,,,percent of total billed charges,,,72.24,,,percent of total billed charges,,,70.66,,,percent of total billed charges,,,88.72,,,percent of total billed charges,,,34.81,,,fee schedule,,,91.35,,,percent of total billed charges,,,91.35,,,percent of total billed charges,,,89.25,,,percent of total billed charges,,,100.8,,,percent of total billed charges,,,99.75,,,percent of total billed charges,,,35.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",94.5,,,percent of total billed charges,,,34.81,,,fee schedule,,,97.65,,,percent of total billed charges,,,99.75,,,percent of total billed charges,,,50.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.99,,,fee schedule,,,30.91,,,fee schedule,,,30.91,,,fee schedule,,,30.29,,,fee schedule,,,34.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82,,,percent of total billed charges,,,95.55,,,percent of total billed charges,,,34.81,,,fee schedule,,,34.81,,,fee schedule,,,39.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MCG IN SITU INT 25 99 CELL,3102969,CDM,311,RC,88274,CPT,,,,,,inpatient,facility,,,128,53.76,108.8,122.88,,108.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.36,,,percent of total billed charges,,,,,,,,,115.2,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MCG IN SITU INT 25 99 CELL,3102969,CDM,311,RC,88274,CPT,,,,,,outpatient,facility,,,128,53.76,34.56,122.88,,108.8,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,88.06,,,percent of total billed charges,,,86.14,,,percent of total billed charges,,,108.16,,,percent of total billed charges,,,42.38,,,fee schedule,,,111.36,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,108.8,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,43.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",115.2,,,percent of total billed charges,,,42.38,,,fee schedule,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,61.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.21,,,fee schedule,,,37.63,,,fee schedule,,,37.63,,,fee schedule,,,36.88,,,fee schedule,,,42.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.97,,,percent of total billed charges,,,116.48,,,percent of total billed charges,,,42.38,,,fee schedule,,,42.38,,,fee schedule,,,42.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MCG IN SITU INT 100 300 CELL,3102977,CDM,311,RC,88275,CPT,,,,,,inpatient,facility,,,154,64.68,130.9,147.84,,130.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.98,,,percent of total billed charges,,,,,,,,,138.6,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MCG IN SITU INT 100 300 CELL,3102977,CDM,311,RC,88275,CPT,,,,,,outpatient,facility,,,154,64.68,41.58,147.84,,130.9,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,105.95,,,percent of total billed charges,,,103.64,,,percent of total billed charges,,,130.13,,,percent of total billed charges,,,51.19,,,fee schedule,,,133.98,,,percent of total billed charges,,,133.98,,,percent of total billed charges,,,130.9,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,52.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",138.6,,,percent of total billed charges,,,51.19,,,fee schedule,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,74.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.11,,,fee schedule,,,45.46,,,fee schedule,,,45.46,,,fee schedule,,,44.55,,,fee schedule,,,51.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",120.27,,,percent of total billed charges,,,140.14,,,percent of total billed charges,,,51.19,,,fee schedule,,,51.19,,,fee schedule,,,49.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TISS NON NEO AF CELL CV,3102985,CDM,311,RC,88235,CPT,,,,,,inpatient,facility,,,451,189.42,383.35,432.96,,383.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.37,,,percent of total billed charges,,,,,,,,,405.9,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TISS NON NEO AF CELL CV,3102985,CDM,311,RC,88235,CPT,,,,,,outpatient,facility,,,451,189.42,121.77,432.96,,383.35,,,percent of total billed charges,,,121.77,,,percent of total billed charges,,,310.29,,,percent of total billed charges,,,303.52,,,percent of total billed charges,,,381.09,,,percent of total billed charges,,,150.3,,,fee schedule,,,392.37,,,percent of total billed charges,,,392.37,,,percent of total billed charges,,,383.35,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,153.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",405.9,,,percent of total billed charges,,,150.3,,,fee schedule,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,217.94,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",202.91,,,fee schedule,,,133.47,,,fee schedule,,,133.47,,,fee schedule,,,130.8,,,fee schedule,,,150.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",352.23,,,percent of total billed charges,,,410.41,,,percent of total billed charges,,,150.3,,,fee schedule,,,150.3,,,fee schedule,,,180.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM STUDY CELLS COUNTED ADDL,3102993,CDM,311,RC,88285,CPT,,,,,,inpatient,facility,,,81,34.02,68.85,77.76,,68.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.47,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM STUDY CELLS COUNTED ADDL,3102993,CDM,311,RC,88285,CPT,,,,,,outpatient,facility,,,81,34.02,21.87,77.76,,68.85,,,percent of total billed charges,,,21.87,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,54.51,,,percent of total billed charges,,,68.44,,,percent of total billed charges,,,26.91,,,fee schedule,,,70.47,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,27.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72.9,,,percent of total billed charges,,,26.91,,,fee schedule,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,39.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.33,,,fee schedule,,,23.9,,,fee schedule,,,23.9,,,fee schedule,,,23.42,,,fee schedule,,,26.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",63.26,,,percent of total billed charges,,,73.71,,,percent of total billed charges,,,26.91,,,fee schedule,,,26.91,,,fee schedule,,,23.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM STUDY RES HIGH ADDL,3103009,CDM,311,RC,88289,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM STUDY RES HIGH ADDL,3103009,CDM,311,RC,88289,CPT,,,,,,outpatient,facility,,,104,43.68,28.08,99.84,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,34.43,,,fee schedule,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,35.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",93.6,,,percent of total billed charges,,,34.43,,,fee schedule,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,49.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.48,,,fee schedule,,,30.57,,,fee schedule,,,30.57,,,fee schedule,,,29.96,,,fee schedule,,,34.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,34.43,,,fee schedule,,,34.43,,,fee schedule,,,42.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM KARYOTYPES ADDL EA,3103017,CDM,311,RC,88280,CPT,,,,,,inpatient,facility,,,101,42.42,85.85,96.96,,85.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.87,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM KARYOTYPES ADDL EA,3103017,CDM,311,RC,88280,CPT,,,,,,outpatient,facility,,,101,42.42,27.27,96.96,,85.85,,,percent of total billed charges,,,27.27,,,percent of total billed charges,,,69.49,,,percent of total billed charges,,,67.97,,,percent of total billed charges,,,85.34,,,percent of total billed charges,,,33.47,,,fee schedule,,,87.87,,,percent of total billed charges,,,87.87,,,percent of total billed charges,,,85.85,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,34.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90.9,,,percent of total billed charges,,,33.47,,,fee schedule,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,48.53,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.18,,,fee schedule,,,29.72,,,fee schedule,,,29.72,,,fee schedule,,,29.13,,,fee schedule,,,33.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.88,,,percent of total billed charges,,,91.91,,,percent of total billed charges,,,33.47,,,fee schedule,,,33.47,,,fee schedule,,,30.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM W BND 5 CLL 1 KRTY,3103025,CDM,311,RC,88261,CPT,,,,,,inpatient,facility,,,794,333.48,674.9,762.24,,674.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.78,,,percent of total billed charges,,,,,,,,,714.6,,,percent of total billed charges,,,762.24,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,738.42,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM W BND 5 CLL 1 KRTY,3103025,CDM,311,RC,88261,CPT,,,,,,outpatient,facility,,,794,333.48,214.38,762.24,,674.9,,,percent of total billed charges,,,214.38,,,percent of total billed charges,,,546.27,,,percent of total billed charges,,,534.36,,,percent of total billed charges,,,670.93,,,percent of total billed charges,,,264.34,,,fee schedule,,,690.78,,,percent of total billed charges,,,690.78,,,percent of total billed charges,,,674.9,,,percent of total billed charges,,,762.24,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,269.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",714.6,,,percent of total billed charges,,,264.34,,,fee schedule,,,738.42,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,383.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",356.86,,,fee schedule,,,234.73,,,fee schedule,,,234.73,,,fee schedule,,,230.04,,,fee schedule,,,264.34,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",620.11,,,percent of total billed charges,,,722.54,,,percent of total billed charges,,,264.34,,,fee schedule,,,264.34,,,fee schedule,,,216.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TISS NON NEO LYMPHOCYTE,3103066,CDM,311,RC,88230,CPT,,,,,,inpatient,facility,,,350,147,297.5,336,,297.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.5,,,percent of total billed charges,,,,,,,,,315,,,percent of total billed charges,,,336,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,325.5,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TISS NON NEO LYMPHOCYTE,3103066,CDM,311,RC,88230,CPT,,,,,,outpatient,facility,,,350,147,94.5,336,,297.5,,,percent of total billed charges,,,94.5,,,percent of total billed charges,,,240.8,,,percent of total billed charges,,,235.55,,,percent of total billed charges,,,295.75,,,percent of total billed charges,,,116.49,,,fee schedule,,,304.5,,,percent of total billed charges,,,304.5,,,percent of total billed charges,,,297.5,,,percent of total billed charges,,,336,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,118.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",315,,,percent of total billed charges,,,116.49,,,fee schedule,,,325.5,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,168.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",157.26,,,fee schedule,,,103.44,,,fee schedule,,,103.44,,,fee schedule,,,101.37,,,fee schedule,,,116.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",273.35,,,percent of total billed charges,,,318.5,,,percent of total billed charges,,,116.49,,,fee schedule,,,116.49,,,fee schedule,,,142.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH CONCENTRATION,3103090,CDM,311,RC,88108,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH CONCENTRATION,3103090,CDM,311,RC,88108,CPT,,,,,,outpatient,facility,,,115,48.3,31.05,110.4,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,,,,,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,40.1,,,fee schedule,,,,,,,,,89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH CONCENTRATION,3103090,CDM,311,RC,88108,CPT,5732,APC,,,,outpatient,facility,,,115,115,18.45,59.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,59.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,18.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH FLUIDS SMEARS,3103108,CDM,311,RC,88104,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH FLUIDS SMEARS,3103108,CDM,311,RC,88104,CPT,,,,,,outpatient,facility,,,115,48.3,31.05,110.4,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,,,,,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,40.1,,,fee schedule,,,,,,,,,89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH FLUIDS SMEARS,3103108,CDM,311,RC,88104,CPT,5732,APC,,,,outpatient,facility,,,115,115,18.45,59.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,59.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,18.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH EVAL FNA INTRP ANDRPT,3103157,CDM,311,RC,88173,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH EVAL FNA INTRP ANDRPT,3103157,CDM,311,RC,88173,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH EVAL FNA INTRP ANDRPT,3103157,CDM,311,RC,88173,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MCG PROBE DNA PROBE EA,3103199,CDM,311,RC,88271,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MCG PROBE DNA PROBE EA,3103199,CDM,311,RC,88271,CPT,,,,,,outpatient,facility,,,65,27.3,17.55,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,21.42,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,21.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,21.42,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,31.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.92,,,fee schedule,,,19.02,,,fee schedule,,,19.02,,,fee schedule,,,18.64,,,fee schedule,,,21.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,21.42,,,fee schedule,,,21.42,,,fee schedule,,,26.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR MANUAL CYTOPATH CERV VAG,3103223,CDM,311,RC,88142,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR MANUAL CYTOPATH CERV VAG,3103223,CDM,311,RC,88142,CPT,,,,,,outpatient,facility,,,61,25.62,16.47,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,20.26,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,20.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,20.26,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,29.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.35,,,fee schedule,,,17.99,,,fee schedule,,,17.99,,,fee schedule,,,17.63,,,fee schedule,,,20.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,20.26,,,fee schedule,,,20.26,,,fee schedule,,,24.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH SMEARS OTH SC ANDIN,3103264,CDM,311,RC,88160,CPT,,,,,,inpatient,facility,,,86,36.12,73.1,82.56,,73.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,77.4,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH SMEARS OTH SC ANDIN,3103264,CDM,311,RC,88160,CPT,,,,,,outpatient,facility,,,86,36.12,23.22,82.56,,73.1,,,percent of total billed charges,,,23.22,,,percent of total billed charges,,,59.17,,,percent of total billed charges,,,57.88,,,percent of total billed charges,,,72.67,,,percent of total billed charges,,,,,,,,,74.82,,,percent of total billed charges,,,74.82,,,percent of total billed charges,,,73.1,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,77.4,,,percent of total billed charges,,,,,,,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,67.17,,,percent of total billed charges,,,78.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH SMEARS OTH SC ANDIN,3103264,CDM,311,RC,88160,CPT,5731,APC,,,,outpatient,facility,,,86,86,13.56,44.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH OTH SRCE SMEARS SC ANDIN,3103272,CDM,311,RC,88161,CPT,,,,,,inpatient,facility,,,86,36.12,73.1,82.56,,73.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,77.4,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH OTH SRCE SMEARS SC ANDIN,3103272,CDM,311,RC,88161,CPT,,,,,,outpatient,facility,,,86,36.12,23.22,82.56,,73.1,,,percent of total billed charges,,,23.22,,,percent of total billed charges,,,59.17,,,percent of total billed charges,,,57.88,,,percent of total billed charges,,,72.67,,,percent of total billed charges,,,,,,,,,74.82,,,percent of total billed charges,,,74.82,,,percent of total billed charges,,,73.1,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,77.4,,,percent of total billed charges,,,,,,,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,67.17,,,percent of total billed charges,,,78.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH OTH SRCE SMEARS SC ANDIN,3103272,CDM,311,RC,88161,CPT,5731,APC,,,,outpatient,facility,,,86,86,13.56,44.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONSULT PATH SURG BLOCK EA ADDL,3103355,CDM,312,RC,88332,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH SURG BLOCK EA ADDL,3103355,CDM,312,RC,88332,CPT,,,,,,outpatient,facility,,,59,24.78,15.93,59,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,,,,,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,59,,,fee schedule,,,59,,,fee schedule,,,59,,,fee schedule,,,,,,,,,46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH SURG BLOCK 1ST,3103363,CDM,312,RC,88331,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH SURG BLOCK 1ST,3103363,CDM,312,RC,88331,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH SURG BLOCK 1ST,3103363,CDM,312,RC,88331,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DECALCIFICATION,3103371,CDM,312,RC,88311,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DECALCIFICATION,3103371,CDM,312,RC,88311,CPT,,,,,,outpatient,facility,,,62,26.04,16.74,62,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,,,,,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,62,,,fee schedule,,,62,,,fee schedule,,,62,,,fee schedule,,,,,,,,,48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 2,3103397,CDM,312,RC,88302,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 2,3103397,CDM,312,RC,88302,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 2,3103397,CDM,312,RC,88302,CPT,5731,APC,,,,outpatient,facility,,,75,75,13.56,44.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PATH GROSS ANDMICRO LVL 3,3103405,CDM,312,RC,88304,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 3,3103405,CDM,312,RC,88304,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 3,3103405,CDM,312,RC,88304,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PATH GROSS ANDMICRO LVL 5,3103421,CDM,312,RC,88307,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 5,3103421,CDM,312,RC,88307,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 5,3103421,CDM,312,RC,88307,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PATH GROSS ANDMICRO LVL 6,3103439,CDM,312,RC,88309,CPT,,,,,,inpatient,facility,,,2330,978.6,1980.5,2236.8,,1980.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.1,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 6,3103439,CDM,312,RC,88309,CPT,,,,,,outpatient,facility,,,2330,978.6,629.1,2236.8,,1980.5,,,percent of total billed charges,,,629.1,,,percent of total billed charges,,,1603.04,,,percent of total billed charges,,,1568.09,,,percent of total billed charges,,,1968.85,,,percent of total billed charges,,,,,,,,,2027.1,,,percent of total billed charges,,,2027.1,,,percent of total billed charges,,,1980.5,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,859.91,,,fee schedule,,,,,,,,,1819.73,,,percent of total billed charges,,,2120.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 6,3103439,CDM,312,RC,88309,CPT,5674,APC,,,,outpatient,facility,,,2330,2330,421.8,1272.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,895.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,1272.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1184.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,877.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,421.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PATH GROSS ONLY LVL 1,3103447,CDM,312,RC,88300,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ONLY LVL 1,3103447,CDM,312,RC,88300,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ONLY LVL 1,3103447,CDM,312,RC,88300,CPT,5731,APC,,,,outpatient,facility,,,75,75,13.56,44.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB STAIN HISTOCHEM W BLOCK FROZEN,3103462,CDM,312,RC,88314,CPT,,,,,,inpatient,facility,,,750,315,637.5,720,,637.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,652.5,,,percent of total billed charges,,,,,,,,,675,,,percent of total billed charges,,,720,,,percent of total billed charges,,,712.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,697.5,,,percent of total billed charges,,,712.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB STAIN HISTOCHEM W BLOCK FROZEN,3103462,CDM,312,RC,88314,CPT,,,,,,outpatient,facility,,,750,315,202.5,750,,637.5,,,percent of total billed charges,,,202.5,,,percent of total billed charges,,,516,,,percent of total billed charges,,,504.75,,,percent of total billed charges,,,633.75,,,percent of total billed charges,,,,,,,,,652.5,,,percent of total billed charges,,,652.5,,,percent of total billed charges,,,637.5,,,percent of total billed charges,,,720,,,percent of total billed charges,,,712.5,,,percent of total billed charges,,,,,,,,,675,,,percent of total billed charges,,,,,,,,,697.5,,,percent of total billed charges,,,712.5,,,percent of total billed charges,,,,,,,,,,,,,,,750,,,fee schedule,,,750,,,fee schedule,,,750,,,fee schedule,,,,,,,,,585.75,,,percent of total billed charges,,,682.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT SLIDES PREP REQ,3103538,CDM,312,RC,88323,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT SLIDES PREP REQ,3103538,CDM,312,RC,88323,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT SLIDES PREP REQ,3103538,CDM,312,RC,88323,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB STAIN SPECIAL 1,3103546,CDM,312,RC,88312,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB STAIN SPECIAL 1,3103546,CDM,312,RC,88312,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB STAIN SPECIAL 1,3103546,CDM,312,RC,88312,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB MYCOPLASMA IGG NS,3103595,CDM,302,RC,86738,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB MYCOPLASMA IGG NS,3103595,CDM,302,RC,86738,CPT,,,,,,outpatient,facility,,,55,23.1,11.52,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,13.24,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,13.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,13.24,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,19.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.87,,,fee schedule,,,11.76,,,fee schedule,,,11.76,,,fee schedule,,,11.52,,,fee schedule,,,13.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,13.24,,,fee schedule,,,13.24,,,fee schedule,,,16.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOZAPINE NORCLOZAPINE,3103637,CDM,301,RC,80159,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOZAPINE NORCLOZAPINE,3103637,CDM,301,RC,80159,CPT,,,,,,outpatient,facility,,,68,28.56,17.53,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,20.15,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,20.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,20.15,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,29.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.2,,,fee schedule,,,17.89,,,fee schedule,,,17.89,,,fee schedule,,,17.53,,,fee schedule,,,20.15,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,20.15,,,fee schedule,,,20.15,,,fee schedule,,,22.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARBAMAZEPINE FREE,3103652,CDM,301,RC,80157,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARBAMAZEPINE FREE,3103652,CDM,301,RC,80157,CPT,,,,,,outpatient,facility,,,90,37.8,11.53,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,13.25,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,13.25,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,16.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TACROLIMUS FK 506 NS,3103686,CDM,301,RC,80197,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TACROLIMUS FK 506 NS,3103686,CDM,301,RC,80197,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.73,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.73,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,19.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.54,,,fee schedule,,,12.19,,,fee schedule,,,12.19,,,fee schedule,,,11.95,,,fee schedule,,,13.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.73,,,fee schedule,,,13.73,,,fee schedule,,,16.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCIUM TOTAL NS,3103728,CDM,301,RC,82310,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCIUM TOTAL NS,3103728,CDM,301,RC,82310,CPT,,,,,,outpatient,facility,,,51,21.42,4.49,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,5.16,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,5.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,5.16,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,7.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.97,,,fee schedule,,,4.58,,,fee schedule,,,4.58,,,fee schedule,,,4.49,,,fee schedule,,,5.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,5.16,,,fee schedule,,,5.16,,,fee schedule,,,6.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHLORIDE STOOL NS,3103736,CDM,301,RC,82438,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHLORIDE STOOL NS,3103736,CDM,301,RC,82438,CPT,,,,,,outpatient,facility,,,58,24.36,2.8,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,5,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,5.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,5,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,7.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.75,,,fee schedule,,,4.44,,,fee schedule,,,4.44,,,fee schedule,,,4.35,,,fee schedule,,,5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,5,,,fee schedule,,,5,,,fee schedule,,,2.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHOLESTEROL SRM BLD WHL TTL NS,3103744,CDM,301,RC,82465,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHOLESTEROL SRM BLD WHL TTL NS,3103744,CDM,301,RC,82465,CPT,,,,,,outpatient,facility,,,56,23.52,3.78,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,4.35,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,4.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,4.35,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,6.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.87,,,fee schedule,,,3.86,,,fee schedule,,,3.86,,,fee schedule,,,3.78,,,fee schedule,,,4.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,4.35,,,fee schedule,,,4.35,,,fee schedule,,,5.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATINE KINASE TOTAL NS,3103777,CDM,301,RC,82550,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATINE KINASE TOTAL NS,3103777,CDM,301,RC,82550,CPT,,,,,,outpatient,facility,,,20,8.4,5.4,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.51,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.51,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.79,,,fee schedule,,,5.78,,,fee schedule,,,5.78,,,fee schedule,,,5.66,,,fee schedule,,,6.51,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.51,,,fee schedule,,,6.51,,,fee schedule,,,7.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATININE URINE NS,3103785,CDM,301,RC,82570,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATININE URINE NS,3103785,CDM,301,RC,82570,CPT,,,,,,outpatient,facility,,,52,21.84,4.51,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,5.18,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,5.18,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CRYOGLOBULIN QL SEMI QN NS,3103793,CDM,301,RC,82595,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CRYOGLOBULIN QL SEMI QN NS,3103793,CDM,301,RC,82595,CPT,,,,,,outpatient,facility,,,63,26.46,3.48,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,6.47,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,6.47,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,3.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRANSFERASE GALACTOSE 1 QN,3103801,CDM,301,RC,82775,CPT,,,,,,inpatient,facility,,,173,72.66,147.05,166.08,,147.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.51,,,percent of total billed charges,,,,,,,,,155.7,,,percent of total billed charges,,,166.08,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,160.89,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERASE GALACTOSE 1 QN,3103801,CDM,301,RC,82775,CPT,,,,,,outpatient,facility,,,173,72.66,18.34,166.08,,147.05,,,percent of total billed charges,,,46.71,,,percent of total billed charges,,,119.02,,,percent of total billed charges,,,116.43,,,percent of total billed charges,,,146.19,,,percent of total billed charges,,,21.07,,,fee schedule,,,150.51,,,percent of total billed charges,,,150.51,,,percent of total billed charges,,,147.05,,,percent of total billed charges,,,166.08,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,21.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",155.7,,,percent of total billed charges,,,21.07,,,fee schedule,,,160.89,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,30.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.44,,,fee schedule,,,18.71,,,fee schedule,,,18.71,,,fee schedule,,,18.34,,,fee schedule,,,21.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",135.11,,,percent of total billed charges,,,157.43,,,percent of total billed charges,,,21.07,,,fee schedule,,,21.07,,,fee schedule,,,25.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG IGA IGD IGG IGM CSF EA,3103819,CDM,301,RC,82784,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG IGA IGD IGG IGM CSF EA,3103819,CDM,301,RC,82784,CPT,,,,,,outpatient,facility,,,63,26.46,8.09,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,9.3,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,9.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,9.3,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,13.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.56,,,fee schedule,,,8.26,,,fee schedule,,,8.26,,,fee schedule,,,8.09,,,fee schedule,,,9.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,9.3,,,fee schedule,,,9.3,,,fee schedule,,,11.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM ACHR BINDING QN,3103850,CDM,302,RC,86041,CPT,,,,,,inpatient,facility,,,70,29.4,59.5,67.2,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.9,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM ACHR BINDING QN,3103850,CDM,302,RC,86041,CPT,,,,,,outpatient,facility,,,70,29.4,16.01,67.2,,59.5,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,47.11,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,18.4,,,fee schedule,,,60.9,,,percent of total billed charges,,,60.9,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,18.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63,,,percent of total billed charges,,,18.4,,,fee schedule,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,26.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.84,,,fee schedule,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,16.01,,,fee schedule,,,18.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",54.67,,,percent of total billed charges,,,63.7,,,percent of total billed charges,,,18.4,,,fee schedule,,,18.4,,,fee schedule,,,,,,,,
LAB IMM GANGLIOSIDE GM TRIPLE QN,3103884,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,70,29.4,59.5,67.2,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.9,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM GANGLIOSIDE GM TRIPLE QN,3103884,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,70,29.4,15.03,67.2,,59.5,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,47.11,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,17.27,,,fee schedule,,,60.9,,,percent of total billed charges,,,60.9,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63,,,percent of total billed charges,,,17.27,,,fee schedule,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",54.67,,,percent of total billed charges,,,63.7,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM GLYCPROT MYELIN ASSC IGM,3103918,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM GLYCPROT MYELIN ASSC IGM,3103918,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,69,28.98,15.03,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,17.27,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,17.27,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LDH NS,3103942,CDM,301,RC,83615,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LDH NS,3103942,CDM,301,RC,83615,CPT,,,,,,outpatient,facility,,,55,23.1,5.25,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,6.04,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,6.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,6.04,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,8.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.15,,,fee schedule,,,5.36,,,fee schedule,,,5.36,,,fee schedule,,,5.25,,,fee schedule,,,6.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,6.04,,,fee schedule,,,6.04,,,fee schedule,,,7.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPASE FLUID BODY NS,3103967,CDM,301,RC,83690,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPASE FLUID BODY NS,3103967,CDM,301,RC,83690,CPT,,,,,,outpatient,facility,,,58,24.36,6,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,6.89,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,7.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,6.89,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,9.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.3,,,fee schedule,,,6.12,,,fee schedule,,,6.12,,,fee schedule,,,6,,,fee schedule,,,6.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,6.89,,,fee schedule,,,6.89,,,fee schedule,,,8.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SODIUM STOOL NS,3104122,CDM,301,RC,84302,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SODIUM STOOL NS,3104122,CDM,301,RC,84302,CPT,,,,,,outpatient,facility,,,58,24.36,4.23,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,4.86,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,4.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,4.86,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,7.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.56,,,fee schedule,,,4.32,,,fee schedule,,,4.32,,,fee schedule,,,4.23,,,fee schedule,,,4.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,4.86,,,fee schedule,,,4.86,,,fee schedule,,,5.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SPCTPHOT PORPHYRINS SERUM,3104130,CDM,301,RC,84311,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SPCTPHOT PORPHYRINS SERUM,3104130,CDM,301,RC,84311,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.1,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.1,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.94,,,fee schedule,,,7.19,,,fee schedule,,,7.19,,,fee schedule,,,7.05,,,fee schedule,,,8.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.1,,,fee schedule,,,8.1,,,fee schedule,,,8.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TESTOSTERONE TOTAL NS,3104148,CDM,301,RC,84403,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TESTOSTERONE TOTAL NS,3104148,CDM,301,RC,84403,CPT,,,,,,outpatient,facility,,,78,32.76,21.06,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,25.81,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,26.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,25.81,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,37.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.84,,,fee schedule,,,22.92,,,fee schedule,,,22.92,,,fee schedule,,,22.46,,,fee schedule,,,25.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,25.81,,,fee schedule,,,25.81,,,fee schedule,,,31.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROXINE T4 FREE NS,3104155,CDM,301,RC,84439,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROXINE T4 FREE NS,3104155,CDM,301,RC,84439,CPT,,,,,,outpatient,facility,,,66,27.72,7.85,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,9.02,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,9.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,9.02,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,13.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.18,,,fee schedule,,,8.01,,,fee schedule,,,8.01,,,fee schedule,,,7.85,,,fee schedule,,,9.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,9.02,,,fee schedule,,,9.02,,,fee schedule,,,11.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRIGLYCERIDES NS,3104163,CDM,301,RC,84478,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIGLYCERIDES NS,3104163,CDM,301,RC,84478,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.74,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.74,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.75,,,fee schedule,,,5.1,,,fee schedule,,,5.1,,,fee schedule,,,5,,,fee schedule,,,5.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.74,,,fee schedule,,,5.74,,,fee schedule,,,7.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING AG ANTITHROMBIN 3 NS,3104213,CDM,305,RC,85301,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING AG ANTITHROMBIN 3 NS,3104213,CDM,305,RC,85301,CPT,,,,,,outpatient,facility,,,69,28.98,9.41,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,10.81,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,11.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,10.81,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,15.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.59,,,fee schedule,,,9.6,,,fee schedule,,,9.6,,,fee schedule,,,9.41,,,fee schedule,,,10.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,10.81,,,fee schedule,,,10.81,,,fee schedule,,,13.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ID PLATELET PATIENT SERUM NS,3104239,CDM,302,RC,86022,CPT,,,,,,inpatient,facility,,,145,60.9,123.25,139.2,,123.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.15,,,percent of total billed charges,,,,,,,,,130.5,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.85,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ID PLATELET PATIENT SERUM NS,3104239,CDM,302,RC,86022,CPT,,,,,,outpatient,facility,,,145,60.9,15.98,139.2,,123.25,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,,99.76,,,percent of total billed charges,,,97.58,,,percent of total billed charges,,,122.52,,,percent of total billed charges,,,18.37,,,fee schedule,,,126.15,,,percent of total billed charges,,,126.15,,,percent of total billed charges,,,123.25,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,18.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",130.5,,,percent of total billed charges,,,18.37,,,fee schedule,,,134.85,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,26.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.8,,,fee schedule,,,16.31,,,fee schedule,,,16.31,,,fee schedule,,,15.98,,,fee schedule,,,18.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",113.25,,,percent of total billed charges,,,131.95,,,percent of total billed charges,,,18.37,,,fee schedule,,,18.37,,,fee schedule,,,22.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT AG C6 COMP EA,3104262,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG C6 COMP EA,3104262,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,12,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,12,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB ANTIMYOCARDIAL FL,3104304,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB ANTIMYOCARDIAL FL,3104304,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,76,31.92,10.49,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,12.05,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,12.05,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB H INFLUENZA AGG PARTICLE,3104338,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB H INFLUENZA AGG PARTICLE,3104338,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,53,22.26,10.05,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,11.54,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,11.54,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CHLAMYDIA TRAC IGG IGA,3104353,CDM,302,RC,86631,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CHLAMYDIA TRAC IGG IGA,3104353,CDM,302,RC,86631,CPT,,,,,,outpatient,facility,,,61,25.62,10.29,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,11.82,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,12.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,11.82,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,17.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.96,,,fee schedule,,,10.5,,,fee schedule,,,10.5,,,fee schedule,,,10.29,,,fee schedule,,,11.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,11.82,,,fee schedule,,,11.82,,,fee schedule,,,14.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB RBC SERUM EA NS,3104361,CDM,300,RC,86850,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB RBC SERUM EA NS,3104361,CDM,300,RC,86850,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB SCR AB RBC SERUM EA NS,3104361,CDM,300,RC,86850,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ELUTION AB RBC EA NS,3104379,CDM,302,RC,86860,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ELUTION AB RBC EA NS,3104379,CDM,302,RC,86860,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ELUTION AB RBC EA NS,3104379,CDM,302,RC,86860,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL AB RBC EA TECH SERUM NS,3104395,CDM,300,RC,86870,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL AB RBC EA TECH SERUM NS,3104395,CDM,300,RC,86870,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PANEL AB RBC EA TECH SERUM NS,3104395,CDM,300,RC,86870,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COOMBS DIR ANTISERUM EA NS,3104403,CDM,302,RC,86880,CPT,,,,,,inpatient,facility,,,173,72.66,147.05,166.08,,147.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,150.51,,,percent of total billed charges,,,,,,,,,155.7,,,percent of total billed charges,,,166.08,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,160.89,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COOMBS DIR ANTISERUM EA NS,3104403,CDM,302,RC,86880,CPT,,,,,,outpatient,facility,,,173,72.66,46.71,166.08,,147.05,,,percent of total billed charges,,,46.71,,,percent of total billed charges,,,119.02,,,percent of total billed charges,,,116.43,,,percent of total billed charges,,,146.19,,,percent of total billed charges,,,,,,,,,150.51,,,percent of total billed charges,,,150.51,,,percent of total billed charges,,,147.05,,,percent of total billed charges,,,166.08,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,,,,,,,155.7,,,percent of total billed charges,,,,,,,,,160.89,,,percent of total billed charges,,,164.35,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,61.17,,,fee schedule,,,,,,,,,135.11,,,percent of total billed charges,,,157.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB COOMBS DIR ANTISERUM EA NS,3104403,CDM,302,RC,86880,CPT,5733,APC,,,,outpatient,facility,,,173,173,31.22,90.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,90.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,62.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,31.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE ABO NS,3104411,CDM,300,RC,86900,CPT,,,,,,inpatient,facility,,,81,34.02,68.85,77.76,,68.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.47,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE ABO NS,3104411,CDM,300,RC,86900,CPT,,,,,,outpatient,facility,,,81,34.02,21.87,130.35,,68.85,,,percent of total billed charges,,,21.87,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,54.51,,,percent of total billed charges,,,68.44,,,percent of total billed charges,,,,,,,,,70.47,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,127.74,,,fee schedule,,,,,,,,,63.26,,,percent of total billed charges,,,73.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE ABO NS,3104411,CDM,300,RC,86900,CPT,5734,APC,,,,outpatient,facility,,,81,81,63.07,189.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,189.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,130.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,63.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE ABO DISCREPANCY,3104429,CDM,300,RC,86900,CPT,,,,,,inpatient,facility,,,349,146.58,296.65,335.04,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.63,,,percent of total billed charges,,,,,,,,,314.1,,,percent of total billed charges,,,335.04,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,324.57,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE ABO DISCREPANCY,3104429,CDM,300,RC,86900,CPT,,,,,,outpatient,facility,,,349,146.58,94.23,335.04,,296.65,,,percent of total billed charges,,,94.23,,,percent of total billed charges,,,240.11,,,percent of total billed charges,,,234.88,,,percent of total billed charges,,,294.9,,,percent of total billed charges,,,,,,,,,303.63,,,percent of total billed charges,,,303.63,,,percent of total billed charges,,,296.65,,,percent of total billed charges,,,335.04,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,314.1,,,percent of total billed charges,,,,,,,,,324.57,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,127.74,,,fee schedule,,,,,,,,,272.57,,,percent of total billed charges,,,317.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE ABO DISCREPANCY,3104429,CDM,300,RC,86900,CPT,5734,APC,,,,outpatient,facility,,,349,349,63.07,189.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,189.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,130.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,63.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE RHD NS,3104437,CDM,300,RC,86901,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE RHD NS,3104437,CDM,300,RC,86901,CPT,,,,,,outpatient,facility,,,71,29.82,19.17,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,,,,,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,40.1,,,fee schedule,,,,,,,,,55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE RHD NS,3104437,CDM,300,RC,86901,CPT,5732,APC,,,,outpatient,facility,,,71,71,18.45,59.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,59.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,18.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE AG RBC PT EA,3104452,CDM,300,RC,86905,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE AG RBC PT EA,3104452,CDM,300,RC,86905,CPT,,,,,,outpatient,facility,,,153,64.26,41.31,366.8,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,,,,,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE AG RBC PT EA,3104452,CDM,300,RC,86905,CPT,5673,APC,,,,outpatient,facility,,,153,153,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE PHENOTYPING RH COMP,3104460,CDM,300,RC,86906,CPT,,,,,,inpatient,facility,,,122,51.24,103.7,117.12,,103.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.14,,,percent of total billed charges,,,,,,,,,109.8,,,percent of total billed charges,,,117.12,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.46,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE PHENOTYPING RH COMP,3104460,CDM,300,RC,86906,CPT,,,,,,outpatient,facility,,,122,51.24,32.94,117.12,,103.7,,,percent of total billed charges,,,32.94,,,percent of total billed charges,,,83.94,,,percent of total billed charges,,,82.11,,,percent of total billed charges,,,103.09,,,percent of total billed charges,,,,,,,,,106.14,,,percent of total billed charges,,,106.14,,,percent of total billed charges,,,103.7,,,percent of total billed charges,,,117.12,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,109.8,,,percent of total billed charges,,,,,,,,,113.46,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,40.1,,,fee schedule,,,,,,,,,95.28,,,percent of total billed charges,,,111.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE PHENOTYPING RH COMP,3104460,CDM,300,RC,86906,CPT,5732,APC,,,,outpatient,facility,,,122,122,18.45,59.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,41.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,40.92,,,fee schedule,,,,,,,,,,,,,,,59.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,40.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,40.92,,,fee schedule,,,40.92,,,fee schedule,,,18.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PRETREAT RBC AB CHEMICAL NS,3104486,CDM,300,RC,86970,CPT,,,,,,inpatient,facility,,,139,58.38,118.15,133.44,,118.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.93,,,percent of total billed charges,,,,,,,,,125.1,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT RBC AB CHEMICAL NS,3104486,CDM,300,RC,86970,CPT,,,,,,outpatient,facility,,,139,58.38,37.53,133.44,,118.15,,,percent of total billed charges,,,37.53,,,percent of total billed charges,,,95.63,,,percent of total billed charges,,,93.55,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,,,,,,,120.93,,,percent of total billed charges,,,120.93,,,percent of total billed charges,,,118.15,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,125.1,,,percent of total billed charges,,,,,,,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,61.17,,,fee schedule,,,,,,,,,108.56,,,percent of total billed charges,,,126.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT RBC AB CHEMICAL NS,3104486,CDM,300,RC,86970,CPT,5733,APC,,,,outpatient,facility,,,139,139,31.22,90.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,90.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,62.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,31.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PRETREAT SERUM ABSORP NS,3104494,CDM,302,RC,86978,CPT,,,,,,inpatient,facility,,,277,116.34,235.45,265.92,,235.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,240.99,,,percent of total billed charges,,,,,,,,,249.3,,,percent of total billed charges,,,265.92,,,percent of total billed charges,,,263.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,257.61,,,percent of total billed charges,,,263.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM ABSORP NS,3104494,CDM,302,RC,86978,CPT,,,,,,outpatient,facility,,,277,116.34,61.17,265.92,,235.45,,,percent of total billed charges,,,74.79,,,percent of total billed charges,,,190.58,,,percent of total billed charges,,,186.42,,,percent of total billed charges,,,234.06,,,percent of total billed charges,,,,,,,,,240.99,,,percent of total billed charges,,,240.99,,,percent of total billed charges,,,235.45,,,percent of total billed charges,,,265.92,,,percent of total billed charges,,,263.15,,,percent of total billed charges,,,,,,,,,249.3,,,percent of total billed charges,,,,,,,,,257.61,,,percent of total billed charges,,,263.15,,,percent of total billed charges,,,,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,61.17,,,fee schedule,,,,,,,,,216.34,,,percent of total billed charges,,,252.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM ABSORP NS,3104494,CDM,302,RC,86978,CPT,5733,APC,,,,outpatient,facility,,,277,277,31.22,90.51,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,62.42,,,fee schedule,,,,,,,,,,,,,,,90.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,62.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,62.42,,,fee schedule,,,62.42,,,fee schedule,,,31.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HLA SEARCH,3104502,CDM,300,RC,86999,CPT,,,,,,inpatient,facility,,,230,96.6,195.5,220.8,,195.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.1,,,percent of total billed charges,,,,,,,,,207,,,percent of total billed charges,,,220.8,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,213.9,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HLA SEARCH,3104502,CDM,300,RC,86999,CPT,,,,,,outpatient,facility,,,230,96.6,29.77,220.8,,195.5,,,percent of total billed charges,,,62.1,,,percent of total billed charges,,,158.24,,,percent of total billed charges,,,154.79,,,percent of total billed charges,,,194.35,,,percent of total billed charges,,,,,,,,,200.1,,,percent of total billed charges,,,200.1,,,percent of total billed charges,,,195.5,,,percent of total billed charges,,,220.8,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,207,,,percent of total billed charges,,,,,,,,,213.9,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,179.63,,,percent of total billed charges,,,209.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB HLA SEARCH,3104502,CDM,300,RC,86999,CPT,5731,APC,,,,outpatient,facility,,,230,230,30.38,161,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,161,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISO VIRUS SHELL VIAL ID W IF NS,3104544,CDM,306,RC,87254,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISO VIRUS SHELL VIAL ID W IF NS,3104544,CDM,306,RC,87254,CPT,,,,,,outpatient,facility,,,59,24.78,14.99,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,19.56,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,19.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,19.56,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,28.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.41,,,fee schedule,,,17.37,,,fee schedule,,,17.37,,,fee schedule,,,17.02,,,fee schedule,,,19.56,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,19.56,,,fee schedule,,,19.56,,,fee schedule,,,14.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ LEGN URINE NS,3104551,CDM,306,RC,87449,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ LEGN URINE NS,3104551,CDM,306,RC,87449,CPT,,,,,,outpatient,facility,,,66,27.72,10.43,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,11.98,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HSV QN,3104569,CDM,306,RC,87530,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HSV QN,3104569,CDM,306,RC,87530,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA PRB AMP NS,3104577,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA PRB AMP NS,3104577,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOTYPE IA HEPATITIS C NS,3104585,CDM,306,RC,87902,CPT,,,,,,inpatient,facility,,,773,324.66,657.05,742.08,,657.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.51,,,percent of total billed charges,,,,,,,,,695.7,,,percent of total billed charges,,,742.08,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,718.89,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOTYPE IA HEPATITIS C NS,3104585,CDM,306,RC,87902,CPT,,,,,,outpatient,facility,,,773,324.66,208.71,742.08,,657.05,,,percent of total billed charges,,,208.71,,,percent of total billed charges,,,531.82,,,percent of total billed charges,,,520.23,,,percent of total billed charges,,,653.18,,,percent of total billed charges,,,257.45,,,fee schedule,,,672.51,,,percent of total billed charges,,,672.51,,,percent of total billed charges,,,657.05,,,percent of total billed charges,,,742.08,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,262.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",695.7,,,percent of total billed charges,,,257.45,,,fee schedule,,,718.89,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,373.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",347.56,,,fee schedule,,,228.62,,,fee schedule,,,228.62,,,fee schedule,,,224.05,,,fee schedule,,,257.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",603.71,,,percent of total billed charges,,,703.43,,,percent of total billed charges,,,257.45,,,fee schedule,,,257.45,,,fee schedule,,,315.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TISS NON NEO LYMPHOCYTE NS,3104593,CDM,311,RC,88230,CPT,,,,,,inpatient,facility,,,350,147,297.5,336,,297.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.5,,,percent of total billed charges,,,,,,,,,315,,,percent of total billed charges,,,336,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,325.5,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TISS NON NEO LYMPHOCYTE NS,3104593,CDM,311,RC,88230,CPT,,,,,,outpatient,facility,,,350,147,94.5,336,,297.5,,,percent of total billed charges,,,94.5,,,percent of total billed charges,,,240.8,,,percent of total billed charges,,,235.55,,,percent of total billed charges,,,295.75,,,percent of total billed charges,,,116.49,,,fee schedule,,,304.5,,,percent of total billed charges,,,304.5,,,percent of total billed charges,,,297.5,,,percent of total billed charges,,,336,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,118.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",315,,,percent of total billed charges,,,116.49,,,fee schedule,,,325.5,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,168.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",157.26,,,fee schedule,,,103.44,,,fee schedule,,,103.44,,,fee schedule,,,101.37,,,fee schedule,,,116.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",273.35,,,percent of total billed charges,,,318.5,,,percent of total billed charges,,,116.49,,,fee schedule,,,116.49,,,fee schedule,,,142.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INHIBIN A,3104619,CDM,302,RC,86336,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INHIBIN A,3104619,CDM,302,RC,86336,CPT,,,,,,outpatient,facility,,,57,23.94,13.56,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,15.59,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,15.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,15.59,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,22.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.05,,,fee schedule,,,13.84,,,fee schedule,,,13.84,,,fee schedule,,,13.56,,,fee schedule,,,15.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,15.59,,,fee schedule,,,15.59,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ESTRIOL SERUM,3104643,CDM,301,RC,82677,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ESTRIOL SERUM,3104643,CDM,301,RC,82677,CPT,,,,,,outpatient,facility,,,73,30.66,19.71,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,24.18,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,24.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,24.18,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,35.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.64,,,fee schedule,,,21.47,,,fee schedule,,,21.47,,,fee schedule,,,21.04,,,fee schedule,,,24.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,24.18,,,fee schedule,,,24.18,,,fee schedule,,,29.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SIROLIMUS,3104650,CDM,301,RC,80195,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SIROLIMUS,3104650,CDM,301,RC,80195,CPT,,,,,,outpatient,facility,,,57,23.94,11.95,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,13.73,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,13.73,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,19.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.54,,,fee schedule,,,12.19,,,fee schedule,,,12.19,,,fee schedule,,,11.95,,,fee schedule,,,13.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,13.73,,,fee schedule,,,13.73,,,fee schedule,,,16.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA RSV IMM OPT,3104692,CDM,306,RC,87807,CPT,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA RSV IMM OPT,3104692,CDM,306,RC,87807,CPT,,,,,,outpatient,facility,,,40,16.8,10.8,38.4,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,13.1,,,fee schedule,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,13.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36,,,percent of total billed charges,,,13.1,,,fee schedule,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,18.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.69,,,fee schedule,,,11.63,,,fee schedule,,,11.63,,,fee schedule,,,11.4,,,fee schedule,,,13.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,13.1,,,fee schedule,,,13.1,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD ICU,31047,CDM,200,RC,,,,,,,,inpatient,facility,,,6600,2772,5610,6600,,5610,,,percent of total billed charges,,,,,,,,,6600,,,case rate,,,6600,,,case rate,,,,,,,,,,,,,,,5742,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,6336,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,,,,,,,6138,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6600,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GASES BLD PH ONLY,3104700,CDM,301,RC,82800,CPT,,,,,,inpatient,facility,,,33,13.86,28.05,31.68,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.71,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GASES BLD PH ONLY,3104700,CDM,301,RC,82800,CPT,,,,,,outpatient,facility,,,33,13.86,8.91,31.68,,28.05,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.21,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,11,,,fee schedule,,,28.71,,,percent of total billed charges,,,28.71,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,11.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.7,,,percent of total billed charges,,,11,,,fee schedule,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,15.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.85,,,fee schedule,,,9.77,,,fee schedule,,,9.77,,,fee schedule,,,9.57,,,fee schedule,,,11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",25.77,,,percent of total billed charges,,,30.03,,,percent of total billed charges,,,11,,,fee schedule,,,11,,,fee schedule,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CREATININE BLOOD,3104718,CDM,301,RC,82565,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CREATININE BLOOD,3104718,CDM,301,RC,82565,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.12,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.12,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.91,,,fee schedule,,,4.55,,,fee schedule,,,4.55,,,fee schedule,,,4.46,,,fee schedule,,,5.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.12,,,fee schedule,,,5.12,,,fee schedule,,,6.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC TROPONIN QN,3104726,CDM,301,RC,84484,CPT,,,,,,inpatient,facility,,,38,15.96,32.3,36.48,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,,,,,,,34.2,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC TROPONIN QN,3104726,CDM,301,RC,84484,CPT,,,,,,outpatient,facility,,,38,15.96,8.21,36.48,,32.3,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,26.14,,,percent of total billed charges,,,25.57,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,12.47,,,fee schedule,,,33.06,,,percent of total billed charges,,,33.06,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,12.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.2,,,percent of total billed charges,,,12.47,,,fee schedule,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,18.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.83,,,fee schedule,,,11.07,,,fee schedule,,,11.07,,,fee schedule,,,10.85,,,fee schedule,,,12.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",29.68,,,percent of total billed charges,,,34.58,,,percent of total billed charges,,,12.47,,,fee schedule,,,12.47,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC AG EIA STREP GROUP A QL,3105020,CDM,306,RC,87430,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC AG EIA STREP GROUP A QL,3105020,CDM,306,RC,87430,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.81,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.81,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.69,,,fee schedule,,,14.93,,,fee schedule,,,14.93,,,fee schedule,,,14.63,,,fee schedule,,,16.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.81,,,fee schedule,,,16.81,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC LACTATE LACTIC ACID,3105038,CDM,301,RC,83605,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC LACTATE LACTIC ACID,3105038,CDM,301,RC,83605,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.57,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.57,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.62,,,fee schedule,,,10.27,,,fee schedule,,,10.27,,,fee schedule,,,10.06,,,fee schedule,,,11.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.57,,,fee schedule,,,11.57,,,fee schedule,,,13.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOTYPE IA HIV 1 REV T,3105046,CDM,306,RC,87901,CPT,,,,,,inpatient,facility,,,773,324.66,657.05,742.08,,657.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,672.51,,,percent of total billed charges,,,,,,,,,695.7,,,percent of total billed charges,,,742.08,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,718.89,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOTYPE IA HIV 1 REV T,3105046,CDM,306,RC,87901,CPT,,,,,,outpatient,facility,,,773,324.66,208.71,742.08,,657.05,,,percent of total billed charges,,,208.71,,,percent of total billed charges,,,531.82,,,percent of total billed charges,,,520.23,,,percent of total billed charges,,,653.18,,,percent of total billed charges,,,257.45,,,fee schedule,,,672.51,,,percent of total billed charges,,,672.51,,,percent of total billed charges,,,657.05,,,percent of total billed charges,,,742.08,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,262.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",695.7,,,percent of total billed charges,,,257.45,,,fee schedule,,,718.89,,,percent of total billed charges,,,734.35,,,percent of total billed charges,,,373.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",347.56,,,fee schedule,,,228.62,,,fee schedule,,,228.62,,,fee schedule,,,224.05,,,fee schedule,,,257.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",603.71,,,percent of total billed charges,,,703.43,,,percent of total billed charges,,,257.45,,,fee schedule,,,257.45,,,fee schedule,,,315.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SICKLING RBC REDUCTION,3105129,CDM,305,RC,85660,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SICKLING RBC REDUCTION,3105129,CDM,305,RC,85660,CPT,,,,,,outpatient,facility,,,56,23.52,4.79,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.51,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.51,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,7.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.44,,,fee schedule,,,4.89,,,fee schedule,,,4.89,,,fee schedule,,,4.79,,,fee schedule,,,5.51,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.51,,,fee schedule,,,5.51,,,fee schedule,,,6.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM 20 25 CELLS,3105178,CDM,311,RC,88264,CPT,,,,,,inpatient,facility,,,434,182.28,368.9,416.64,,368.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.58,,,percent of total billed charges,,,,,,,,,390.6,,,percent of total billed charges,,,416.64,,,percent of total billed charges,,,412.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,403.62,,,percent of total billed charges,,,412.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM 20 25 CELLS,3105178,CDM,311,RC,88264,CPT,,,,,,outpatient,facility,,,434,182.28,117.18,416.64,,368.9,,,percent of total billed charges,,,117.18,,,percent of total billed charges,,,298.59,,,percent of total billed charges,,,292.08,,,percent of total billed charges,,,366.73,,,percent of total billed charges,,,144.61,,,fee schedule,,,377.58,,,percent of total billed charges,,,377.58,,,percent of total billed charges,,,368.9,,,percent of total billed charges,,,416.64,,,percent of total billed charges,,,412.3,,,percent of total billed charges,,,147.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",390.6,,,percent of total billed charges,,,144.61,,,fee schedule,,,403.62,,,percent of total billed charges,,,412.3,,,percent of total billed charges,,,209.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",195.22,,,fee schedule,,,128.41,,,fee schedule,,,128.41,,,fee schedule,,,125.84,,,fee schedule,,,144.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",338.95,,,percent of total billed charges,,,394.94,,,percent of total billed charges,,,144.61,,,fee schedule,,,144.61,,,fee schedule,,,152.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CARBOXYHEMOGLOBIN QN,3105194,CDM,301,RC,82375,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CARBOXYHEMOGLOBIN QN,3105194,CDM,301,RC,82375,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.32,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.32,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.63,,,fee schedule,,,10.94,,,fee schedule,,,10.94,,,fee schedule,,,10.72,,,fee schedule,,,12.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.32,,,fee schedule,,,12.32,,,fee schedule,,,15.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC GASES BLD ANY COMBO W SAT O2,3105210,CDM,301,RC,82805,CPT,,,,,,inpatient,facility,,,237,99.54,201.45,227.52,,201.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.19,,,percent of total billed charges,,,,,,,,,213.3,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GASES BLD ANY COMBO W SAT O2,3105210,CDM,301,RC,82805,CPT,,,,,,outpatient,facility,,,237,99.54,34.8,227.52,,201.45,,,percent of total billed charges,,,63.99,,,percent of total billed charges,,,163.06,,,percent of total billed charges,,,159.5,,,percent of total billed charges,,,200.26,,,percent of total billed charges,,,78.77,,,fee schedule,,,206.19,,,percent of total billed charges,,,206.19,,,percent of total billed charges,,,201.45,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,80.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",213.3,,,percent of total billed charges,,,78.77,,,fee schedule,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,114.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",106.34,,,fee schedule,,,69.95,,,fee schedule,,,69.95,,,fee schedule,,,68.55,,,fee schedule,,,78.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",185.1,,,percent of total billed charges,,,215.67,,,percent of total billed charges,,,78.77,,,fee schedule,,,78.77,,,fee schedule,,,34.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ HEP B SURF,3105244,CDM,306,RC,87341,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ HEP B SURF,3105244,CDM,306,RC,87341,CPT,,,,,,outpatient,facility,,,58,24.36,8.99,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,10.33,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,10.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,10.33,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,14.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.95,,,fee schedule,,,9.17,,,fee schedule,,,9.17,,,fee schedule,,,8.99,,,fee schedule,,,10.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,10.33,,,fee schedule,,,10.33,,,fee schedule,,,12.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMIKACIN PEAK,3105343,CDM,301,RC,80150,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMIKACIN PEAK,3105343,CDM,301,RC,80150,CPT,,,,,,outpatient,facility,,,59,24.78,13.12,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,15.08,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,15.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,15.08,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,21.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.36,,,fee schedule,,,13.39,,,fee schedule,,,13.39,,,fee schedule,,,13.12,,,fee schedule,,,15.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,15.08,,,fee schedule,,,15.08,,,fee schedule,,,18.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMIKACIN RANDOM,3105350,CDM,301,RC,80150,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMIKACIN RANDOM,3105350,CDM,301,RC,80150,CPT,,,,,,outpatient,facility,,,62,26.04,13.12,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,15.08,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,15.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,15.08,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,21.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.36,,,fee schedule,,,13.39,,,fee schedule,,,13.39,,,fee schedule,,,13.12,,,fee schedule,,,15.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,15.08,,,fee schedule,,,15.08,,,fee schedule,,,18.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMIKACIN TROUGH,3105368,CDM,301,RC,80150,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMIKACIN TROUGH,3105368,CDM,301,RC,80150,CPT,,,,,,outpatient,facility,,,62,26.04,13.12,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,15.08,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,15.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,15.08,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,21.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.36,,,fee schedule,,,13.39,,,fee schedule,,,13.39,,,fee schedule,,,13.12,,,fee schedule,,,15.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,15.08,,,fee schedule,,,15.08,,,fee schedule,,,18.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB GBM QN NS,3105392,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB GBM QN NS,3105392,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.27,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.27,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AG ANTI SOLUBLE LIVER QN,3105400,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AG ANTI SOLUBLE LIVER QN,3105400,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,71,29.82,15.03,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,17.27,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,17.27,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACIDS FATTY VERY LONG CHAIN,3105434,CDM,301,RC,82726,CPT,,,,,,inpatient,facility,,,255,107.1,216.75,244.8,,216.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,221.85,,,percent of total billed charges,,,,,,,,,229.5,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,237.15,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACIDS FATTY VERY LONG CHAIN,3105434,CDM,301,RC,82726,CPT,,,,,,outpatient,facility,,,255,107.1,14.06,244.8,,216.75,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,175.44,,,percent of total billed charges,,,171.61,,,percent of total billed charges,,,215.47,,,percent of total billed charges,,,19.75,,,fee schedule,,,221.85,,,percent of total billed charges,,,221.85,,,percent of total billed charges,,,216.75,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,20.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",229.5,,,percent of total billed charges,,,19.75,,,fee schedule,,,237.15,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,28.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.66,,,fee schedule,,,17.54,,,fee schedule,,,17.54,,,fee schedule,,,17.19,,,fee schedule,,,19.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",199.16,,,percent of total billed charges,,,232.05,,,percent of total billed charges,,,19.75,,,fee schedule,,,19.75,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB QN NS,3105467,CDM,302,RC,86317,CPT,,,,,,inpatient,facility,,,142,59.64,120.7,136.32,,120.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,123.54,,,percent of total billed charges,,,,,,,,,127.8,,,percent of total billed charges,,,136.32,,,percent of total billed charges,,,134.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,132.06,,,percent of total billed charges,,,134.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB QN NS,3105467,CDM,302,RC,86317,CPT,,,,,,outpatient,facility,,,142,59.64,13.04,136.32,,120.7,,,percent of total billed charges,,,38.34,,,percent of total billed charges,,,97.7,,,percent of total billed charges,,,95.57,,,percent of total billed charges,,,119.99,,,percent of total billed charges,,,14.99,,,fee schedule,,,123.54,,,percent of total billed charges,,,123.54,,,percent of total billed charges,,,120.7,,,percent of total billed charges,,,136.32,,,percent of total billed charges,,,134.9,,,percent of total billed charges,,,15.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",127.8,,,percent of total billed charges,,,14.99,,,fee schedule,,,132.06,,,percent of total billed charges,,,134.9,,,percent of total billed charges,,,21.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.24,,,fee schedule,,,13.31,,,fee schedule,,,13.31,,,fee schedule,,,13.04,,,fee schedule,,,14.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",110.9,,,percent of total billed charges,,,129.22,,,percent of total billed charges,,,14.99,,,fee schedule,,,14.99,,,fee schedule,,,18.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA PARVOVIRUS PCR PRB AMP,3105475,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA PARVOVIRUS PCR PRB AMP,3105475,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALBUMIN SRM PLASMA BLD WHL NS,3105509,CDM,301,RC,82040,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALBUMIN SRM PLASMA BLD WHL NS,3105509,CDM,301,RC,82040,CPT,,,,,,outpatient,facility,,,63,26.46,4.31,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,4.95,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,5.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,4.95,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,7.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.68,,,fee schedule,,,4.4,,,fee schedule,,,4.4,,,fee schedule,,,4.31,,,fee schedule,,,4.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,4.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOGLOBIN FRCTN ANDQN ELECTRO NS,3105525,CDM,301,RC,83020,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOGLOBIN FRCTN ANDQN ELECTRO NS,3105525,CDM,301,RC,83020,CPT,,,,,,outpatient,facility,,,71,29.82,11.2,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,12.87,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,13.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,12.87,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,18.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.37,,,fee schedule,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,11.2,,,fee schedule,,,12.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,12.87,,,fee schedule,,,12.87,,,fee schedule,,,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISO VIRUS INOC TISSUE NS,3105533,CDM,306,RC,87252,CPT,,,,,,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISO VIRUS INOC TISSUE NS,3105533,CDM,306,RC,87252,CPT,,,,,,outpatient,facility,,,100,42,22.69,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,26.07,,,fee schedule,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90,,,percent of total billed charges,,,26.07,,,fee schedule,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,37.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.19,,,fee schedule,,,23.15,,,fee schedule,,,23.15,,,fee schedule,,,22.69,,,fee schedule,,,26.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,26.07,,,fee schedule,,,26.07,,,fee schedule,,,31.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC BILIRUBIN TOTAL TRANSQ,3105558,CDM,301,RC,88720,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC BILIRUBIN TOTAL TRANSQ,3105558,CDM,301,RC,88720,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.02,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.02,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.78,,,fee schedule,,,4.46,,,fee schedule,,,4.46,,,fee schedule,,,4.37,,,fee schedule,,,5.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.02,,,fee schedule,,,5.02,,,fee schedule,,,6.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACYLCARNITINES QN EA,3105608,CDM,301,RC,82017,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACYLCARNITINES QN EA,3105608,CDM,301,RC,82017,CPT,,,,,,outpatient,facility,,,115,48.3,5.84,110.4,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,16.87,,,fee schedule,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,17.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",103.5,,,percent of total billed charges,,,16.87,,,fee schedule,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,24.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.77,,,fee schedule,,,14.98,,,fee schedule,,,14.98,,,fee schedule,,,14.68,,,fee schedule,,,16.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,16.87,,,fee schedule,,,16.87,,,fee schedule,,,5.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA CENTROMERE B,3105616,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA CENTROMERE B,3105616,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,60,25.2,15.6,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,17.93,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,17.93,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LACTOFERRIN FECAL QL,3105657,CDM,301,RC,83630,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LACTOFERRIN FECAL QL,3105657,CDM,301,RC,83630,CPT,,,,,,outpatient,facility,,,73,30.66,17.14,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,19.7,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,20.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,19.7,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,28.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.6,,,fee schedule,,,17.49,,,fee schedule,,,17.49,,,fee schedule,,,17.14,,,fee schedule,,,19.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,19.7,,,fee schedule,,,19.7,,,fee schedule,,,24.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA STREP GROUP A IMM OPT,3105681,CDM,306,RC,87880,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA STREP GROUP A IMM OPT,3105681,CDM,306,RC,87880,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.53,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.53,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.32,,,fee schedule,,,14.68,,,fee schedule,,,14.68,,,fee schedule,,,14.39,,,fee schedule,,,16.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.53,,,fee schedule,,,16.53,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HTLV HIV CONFIRMATORY NS,3105723,CDM,302,RC,86689,CPT,,,,,,inpatient,facility,,,217,91.14,184.45,208.32,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.79,,,percent of total billed charges,,,,,,,,,195.3,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HTLV HIV CONFIRMATORY NS,3105723,CDM,302,RC,86689,CPT,,,,,,outpatient,facility,,,217,91.14,16.84,208.32,,184.45,,,percent of total billed charges,,,58.59,,,percent of total billed charges,,,149.3,,,percent of total billed charges,,,146.04,,,percent of total billed charges,,,183.36,,,percent of total billed charges,,,19.35,,,fee schedule,,,188.79,,,percent of total billed charges,,,188.79,,,percent of total billed charges,,,184.45,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,19.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",195.3,,,percent of total billed charges,,,19.35,,,fee schedule,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,28.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.12,,,fee schedule,,,17.18,,,fee schedule,,,17.18,,,fee schedule,,,16.84,,,fee schedule,,,19.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",169.48,,,percent of total billed charges,,,197.47,,,percent of total billed charges,,,19.35,,,fee schedule,,,19.35,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CROSS LINKS N TELOPEPTIDE,3105772,CDM,301,RC,82523,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CROSS LINKS N TELOPEPTIDE,3105772,CDM,301,RC,82523,CPT,,,,,,outpatient,facility,,,68,28.56,16.26,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,18.68,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,19.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,18.68,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,27.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.22,,,fee schedule,,,16.59,,,fee schedule,,,16.59,,,fee schedule,,,16.26,,,fee schedule,,,18.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,18.68,,,fee schedule,,,18.68,,,fee schedule,,,22.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LEAD BLOOD NS,3105855,CDM,301,RC,83655,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LEAD BLOOD NS,3105855,CDM,301,RC,83655,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.11,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.11,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.35,,,fee schedule,,,10.75,,,fee schedule,,,10.75,,,fee schedule,,,10.54,,,fee schedule,,,12.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.11,,,fee schedule,,,12.11,,,fee schedule,,,14.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR METABOLIC NEWBORN,3105871,CDM,300,RC,S3620,HCPCS,,,,,,inpatient,facility,,,157,65.94,133.45,150.72,,133.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.59,,,percent of total billed charges,,,,,,,,,141.3,,,percent of total billed charges,,,150.72,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.01,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR METABOLIC NEWBORN,3105871,CDM,300,RC,S3620,HCPCS,,,,,,outpatient,facility,,,157,65.94,42.39,157,,133.45,,,percent of total billed charges,,,42.39,,,percent of total billed charges,,,108.02,,,percent of total billed charges,,,105.66,,,percent of total billed charges,,,132.66,,,percent of total billed charges,,,,,,,,,136.59,,,percent of total billed charges,,,136.59,,,percent of total billed charges,,,133.45,,,percent of total billed charges,,,150.72,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,,,,,,,141.3,,,percent of total billed charges,,,,,,,,,146.01,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,94.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,133.2,,,fee schedule,,,133.2,,,fee schedule,,,130.54,,,fee schedule,,,157,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",122.62,,,percent of total billed charges,,,142.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB AB LYME DISEASE CONFIRMATORY,3106036,CDM,302,RC,86617,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB LYME DISEASE CONFIRMATORY,3106036,CDM,302,RC,86617,CPT,,,,,,outpatient,facility,,,61,25.62,13.48,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,15.49,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,15.49,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,22.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.91,,,fee schedule,,,13.76,,,fee schedule,,,13.76,,,fee schedule,,,13.48,,,fee schedule,,,15.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,15.49,,,fee schedule,,,15.49,,,fee schedule,,,18.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TISS NON NEO SKIN BX NS,3106051,CDM,311,RC,88233,CPT,,,,,,inpatient,facility,,,423,177.66,359.55,406.08,,359.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,368.01,,,percent of total billed charges,,,,,,,,,380.7,,,percent of total billed charges,,,406.08,,,percent of total billed charges,,,401.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,393.39,,,percent of total billed charges,,,401.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TISS NON NEO SKIN BX NS,3106051,CDM,311,RC,88233,CPT,,,,,,outpatient,facility,,,423,177.66,114.21,406.08,,359.55,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,291.02,,,percent of total billed charges,,,284.68,,,percent of total billed charges,,,357.44,,,percent of total billed charges,,,140.73,,,fee schedule,,,368.01,,,percent of total billed charges,,,368.01,,,percent of total billed charges,,,359.55,,,percent of total billed charges,,,406.08,,,percent of total billed charges,,,401.85,,,percent of total billed charges,,,143.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",380.7,,,percent of total billed charges,,,140.73,,,fee schedule,,,393.39,,,percent of total billed charges,,,401.85,,,percent of total billed charges,,,204.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",189.99,,,fee schedule,,,124.97,,,fee schedule,,,124.97,,,fee schedule,,,122.47,,,fee schedule,,,140.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",330.36,,,percent of total billed charges,,,384.93,,,percent of total billed charges,,,140.73,,,fee schedule,,,140.73,,,fee schedule,,,172.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CROSSMATCH ELECTRONIC,3106168,CDM,300,RC,86923,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH ELECTRONIC,3106168,CDM,300,RC,86923,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CROSSMATCH ELECTRONIC,3106168,CDM,300,RC,86923,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB PEPTIDE CYCLIC CITRUL,3106176,CDM,302,RC,86200,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB PEPTIDE CYCLIC CITRUL,3106176,CDM,302,RC,86200,CPT,,,,,,outpatient,facility,,,60,25.2,11.27,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,12.95,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,13.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,12.95,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,18.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.48,,,fee schedule,,,11.5,,,fee schedule,,,11.5,,,fee schedule,,,11.27,,,fee schedule,,,12.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,12.95,,,fee schedule,,,12.95,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD ICU,31062,CDM,200,RC,,,,,,,,inpatient,facility,,,6600,2772,5610,6600,,5610,,,percent of total billed charges,,,,,,,,,6600,,,case rate,,,6600,,,case rate,,,,,,,,,,,,,,,5742,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,6336,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,,,,,,,6138,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6600,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NIACIN,3106390,CDM,301,RC,84591,CPT,,,,,,inpatient,facility,,,94,39.48,79.9,90.24,,79.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.78,,,percent of total billed charges,,,,,,,,,84.6,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NIACIN,3106390,CDM,301,RC,84591,CPT,,,,,,outpatient,facility,,,94,39.48,12.27,90.24,,79.9,,,percent of total billed charges,,,25.38,,,percent of total billed charges,,,64.67,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,79.43,,,percent of total billed charges,,,17.06,,,fee schedule,,,81.78,,,percent of total billed charges,,,81.78,,,percent of total billed charges,,,79.9,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.6,,,percent of total billed charges,,,17.06,,,fee schedule,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,24.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.03,,,fee schedule,,,15.15,,,fee schedule,,,15.15,,,fee schedule,,,14.85,,,fee schedule,,,17.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",73.41,,,percent of total billed charges,,,85.54,,,percent of total billed charges,,,17.06,,,fee schedule,,,17.06,,,fee schedule,,,12.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALLG IGG QN SEMI QN EA,3106440,CDM,302,RC,86001,CPT,,,,,,inpatient,facility,,,109,45.78,92.65,104.64,,92.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.83,,,percent of total billed charges,,,,,,,,,98.1,,,percent of total billed charges,,,104.64,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.37,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALLG IGG QN SEMI QN EA,3106440,CDM,302,RC,86001,CPT,,,,,,outpatient,facility,,,109,45.78,5.87,104.64,,92.65,,,percent of total billed charges,,,29.43,,,percent of total billed charges,,,74.99,,,percent of total billed charges,,,73.36,,,percent of total billed charges,,,92.11,,,percent of total billed charges,,,7.82,,,fee schedule,,,94.83,,,percent of total billed charges,,,94.83,,,percent of total billed charges,,,92.65,,,percent of total billed charges,,,104.64,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,7.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",98.1,,,percent of total billed charges,,,7.82,,,fee schedule,,,101.37,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,11.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.56,,,fee schedule,,,6.94,,,fee schedule,,,6.94,,,fee schedule,,,6.8,,,fee schedule,,,7.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",85.13,,,percent of total billed charges,,,99.19,,,percent of total billed charges,,,7.82,,,fee schedule,,,7.82,,,fee schedule,,,5.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONSULT PATH SURG CYTO INITIAL,3106481,CDM,311,RC,88333,CPT,,,,,,inpatient,facility,,,2330,978.6,1980.5,2236.8,,1980.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.1,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH SURG CYTO INITIAL,3106481,CDM,311,RC,88333,CPT,,,,,,outpatient,facility,,,2330,978.6,629.1,2236.8,,1980.5,,,percent of total billed charges,,,629.1,,,percent of total billed charges,,,1603.04,,,percent of total billed charges,,,1568.09,,,percent of total billed charges,,,1968.85,,,percent of total billed charges,,,,,,,,,2027.1,,,percent of total billed charges,,,2027.1,,,percent of total billed charges,,,1980.5,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,859.91,,,fee schedule,,,,,,,,,1819.73,,,percent of total billed charges,,,2120.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH SURG CYTO INITIAL,3106481,CDM,311,RC,88333,CPT,5674,APC,,,,outpatient,facility,,,2330,2330,421.8,1272.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,895.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,1272.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1184.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,877.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,421.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONSULT PATH SURG CYTO EA ADDL,3106499,CDM,311,RC,88334,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH SURG CYTO EA ADDL,3106499,CDM,311,RC,88334,CPT,,,,,,outpatient,facility,,,65,27.3,17.55,65,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,,,,,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,65,,,fee schedule,,,65,,,fee schedule,,,65,,,fee schedule,,,,,,,,,50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB RENIN NS,3106531,CDM,301,RC,84244,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RENIN NS,3106531,CDM,301,RC,84244,CPT,,,,,,outpatient,facility,,,66,27.72,17.82,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,21.99,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,22.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,21.99,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,31.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.69,,,fee schedule,,,19.53,,,fee schedule,,,19.53,,,fee schedule,,,19.14,,,fee schedule,,,21.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,21.99,,,fee schedule,,,21.99,,,fee schedule,,,26.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT PHENOTYPE IA DRUG,3106556,CDM,306,RC,87900,CPT,,,,,,inpatient,facility,,,392,164.64,333.2,376.32,,333.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.04,,,percent of total billed charges,,,,,,,,,352.8,,,percent of total billed charges,,,376.32,,,percent of total billed charges,,,372.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,364.56,,,percent of total billed charges,,,372.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT PHENOTYPE IA DRUG,3106556,CDM,306,RC,87900,CPT,,,,,,outpatient,facility,,,392,164.64,105.84,376.32,,333.2,,,percent of total billed charges,,,105.84,,,percent of total billed charges,,,269.7,,,percent of total billed charges,,,263.82,,,percent of total billed charges,,,331.24,,,percent of total billed charges,,,130.35,,,fee schedule,,,341.04,,,percent of total billed charges,,,341.04,,,percent of total billed charges,,,333.2,,,percent of total billed charges,,,376.32,,,percent of total billed charges,,,372.4,,,percent of total billed charges,,,132.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",352.8,,,percent of total billed charges,,,130.35,,,fee schedule,,,364.56,,,percent of total billed charges,,,372.4,,,percent of total billed charges,,,189.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.97,,,fee schedule,,,115.75,,,fee schedule,,,115.75,,,fee schedule,,,113.44,,,fee schedule,,,130.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",306.15,,,percent of total billed charges,,,356.72,,,percent of total billed charges,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,159.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC OTHER NS,3106572,CDM,306,RC,87070,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC OTHER NS,3106572,CDM,306,RC,87070,CPT,,,,,,outpatient,facility,,,68,28.56,4.6,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,8.62,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,8.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,8.62,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,12.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.64,,,fee schedule,,,7.65,,,fee schedule,,,7.65,,,fee schedule,,,7.5,,,fee schedule,,,8.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,8.62,,,fee schedule,,,8.62,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ GIARDIA,3106622,CDM,306,RC,87329,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ GIARDIA,3106622,CDM,306,RC,87329,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.98,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM TRYPTASE QN,3106689,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM TRYPTASE QN,3106689,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,77,32.34,15.03,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,17.27,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,17.27,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMMUNOFIXATION EP SERUM,3106721,CDM,302,RC,86334,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMMUNOFIXATION EP SERUM,3106721,CDM,302,RC,86334,CPT,,,,,,outpatient,facility,,,68,28.56,18.36,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,22.34,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,22.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,22.34,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,32.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.16,,,fee schedule,,,19.84,,,fee schedule,,,19.84,,,fee schedule,,,19.44,,,fee schedule,,,22.34,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,22.34,,,fee schedule,,,22.34,,,fee schedule,,,27.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRANSFERASE AMINO ALANINE NS,3106911,CDM,301,RC,84460,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERASE AMINO ALANINE NS,3106911,CDM,301,RC,84460,CPT,,,,,,outpatient,facility,,,59,24.78,4.62,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,5.3,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,5.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,5.3,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,7.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.16,,,fee schedule,,,4.71,,,fee schedule,,,4.71,,,fee schedule,,,4.62,,,fee schedule,,,5.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,5.3,,,fee schedule,,,5.3,,,fee schedule,,,6.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VITAMIN D 25 HYDROXY W FRAC,3107026,CDM,301,RC,82306,CPT,,,,,,inpatient,facility,,,89,37.38,75.65,85.44,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,,,,,,,80.1,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VITAMIN D 25 HYDROXY W FRAC,3107026,CDM,301,RC,82306,CPT,,,,,,outpatient,facility,,,89,37.38,24.03,85.44,,75.65,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,61.23,,,percent of total billed charges,,,59.9,,,percent of total billed charges,,,75.2,,,percent of total billed charges,,,29.6,,,fee schedule,,,77.43,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,75.65,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,30.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",80.1,,,percent of total billed charges,,,29.6,,,fee schedule,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,42.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.96,,,fee schedule,,,26.28,,,fee schedule,,,26.28,,,fee schedule,,,25.75,,,fee schedule,,,29.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",69.51,,,percent of total billed charges,,,80.99,,,percent of total billed charges,,,29.6,,,fee schedule,,,29.6,,,fee schedule,,,36.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB BACTERIUM NONSPECIFIED NS,3107133,CDM,302,RC,86609,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB BACTERIUM NONSPECIFIED NS,3107133,CDM,302,RC,86609,CPT,,,,,,outpatient,facility,,,153,64.26,11.21,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,12.88,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA NS,3107141,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA NS,3107141,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,65,27.3,15.6,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,17.93,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,17.93,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ INFLUENZA A B,3107166,CDM,306,RC,87400,CPT,,,,,,inpatient,facility,,,43,18.06,36.55,41.28,,36.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.41,,,percent of total billed charges,,,,,,,,,38.7,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ INFLUENZA A B,3107166,CDM,306,RC,87400,CPT,,,,,,outpatient,facility,,,43,18.06,11.61,41.28,,36.55,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,29.58,,,percent of total billed charges,,,28.94,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,14.13,,,fee schedule,,,37.41,,,percent of total billed charges,,,37.41,,,percent of total billed charges,,,36.55,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,14.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",38.7,,,percent of total billed charges,,,14.13,,,fee schedule,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,20.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.08,,,fee schedule,,,12.55,,,fee schedule,,,12.55,,,fee schedule,,,12.3,,,fee schedule,,,14.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",33.58,,,percent of total billed charges,,,39.13,,,percent of total billed charges,,,14.13,,,fee schedule,,,14.13,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA CANDIDA PRB DIR,3107224,CDM,306,RC,87480,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CANDIDA PRB DIR,3107224,CDM,306,RC,87480,CPT,,,,,,outpatient,facility,,,90,37.8,17.44,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,20.05,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,20.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,20.05,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,29.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.07,,,fee schedule,,,17.8,,,fee schedule,,,17.8,,,fee schedule,,,17.44,,,fee schedule,,,20.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,20.05,,,fee schedule,,,20.05,,,fee schedule,,,24.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA GARDNERELLA VAG PRB DIR,3107232,CDM,306,RC,87510,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA GARDNERELLA VAG PRB DIR,3107232,CDM,306,RC,87510,CPT,,,,,,outpatient,facility,,,90,37.8,17.44,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,20.05,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,20.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,20.05,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,29.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.07,,,fee schedule,,,17.8,,,fee schedule,,,17.8,,,fee schedule,,,17.44,,,fee schedule,,,20.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,20.05,,,fee schedule,,,20.05,,,fee schedule,,,24.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA TRICHOMONAS VAG PRB DIR,3107240,CDM,306,RC,87660,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA TRICHOMONAS VAG PRB DIR,3107240,CDM,306,RC,87660,CPT,,,,,,outpatient,facility,,,61,25.62,16.47,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,20.05,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,20.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,20.05,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,29.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.07,,,fee schedule,,,17.8,,,fee schedule,,,17.8,,,fee schedule,,,17.44,,,fee schedule,,,20.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,20.05,,,fee schedule,,,20.05,,,fee schedule,,,24.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM RIA PTH REL PROT QN,3107265,CDM,301,RC,83519,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM RIA PTH REL PROT QN,3107265,CDM,301,RC,83519,CPT,,,,,,outpatient,facility,,,72,30.24,16.01,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,18.4,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,18.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,18.4,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,26.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.84,,,fee schedule,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,16.01,,,fee schedule,,,18.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,18.4,,,fee schedule,,,18.4,,,fee schedule,,,16.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH CERV VAG AUTO ANDMANUAL,3107273,CDM,311,RC,88175,CPT,,,,,,inpatient,facility,,,162,68.04,137.7,155.52,,137.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,140.94,,,percent of total billed charges,,,,,,,,,145.8,,,percent of total billed charges,,,155.52,,,percent of total billed charges,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,150.66,,,percent of total billed charges,,,153.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH CERV VAG AUTO ANDMANUAL,3107273,CDM,311,RC,88175,CPT,,,,,,outpatient,facility,,,162,68.04,23.16,155.52,,137.7,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,111.46,,,percent of total billed charges,,,109.03,,,percent of total billed charges,,,136.89,,,percent of total billed charges,,,26.61,,,fee schedule,,,140.94,,,percent of total billed charges,,,140.94,,,percent of total billed charges,,,137.7,,,percent of total billed charges,,,155.52,,,percent of total billed charges,,,153.9,,,percent of total billed charges,,,27.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",145.8,,,percent of total billed charges,,,26.61,,,fee schedule,,,150.66,,,percent of total billed charges,,,153.9,,,percent of total billed charges,,,38.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.92,,,fee schedule,,,23.63,,,fee schedule,,,23.63,,,fee schedule,,,23.16,,,fee schedule,,,26.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",126.52,,,percent of total billed charges,,,147.42,,,percent of total billed charges,,,26.61,,,fee schedule,,,26.61,,,fee schedule,,,32.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AFP L3 ISOFORM FRAC ANDAFP TOTAL,3107356,CDM,301,RC,82107,CPT,,,,,,inpatient,facility,,,194,81.48,164.9,186.24,,164.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,168.78,,,percent of total billed charges,,,,,,,,,174.6,,,percent of total billed charges,,,186.24,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,180.42,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AFP L3 ISOFORM FRAC ANDAFP TOTAL,3107356,CDM,301,RC,82107,CPT,,,,,,outpatient,facility,,,194,81.48,52.38,186.24,,164.9,,,percent of total billed charges,,,52.38,,,percent of total billed charges,,,133.47,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,163.93,,,percent of total billed charges,,,64.41,,,fee schedule,,,168.78,,,percent of total billed charges,,,168.78,,,percent of total billed charges,,,164.9,,,percent of total billed charges,,,186.24,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,65.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",174.6,,,percent of total billed charges,,,64.41,,,fee schedule,,,180.42,,,percent of total billed charges,,,184.3,,,percent of total billed charges,,,93.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",86.95,,,fee schedule,,,57.2,,,fee schedule,,,57.2,,,fee schedule,,,56.06,,,fee schedule,,,64.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",151.51,,,percent of total billed charges,,,176.54,,,percent of total billed charges,,,64.41,,,fee schedule,,,64.41,,,fee schedule,,,75.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN PHOSPHOLIPASE A2,3107364,CDM,301,RC,83698,CPT,,,,,,inpatient,facility,,,139,58.38,118.15,133.44,,118.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.93,,,percent of total billed charges,,,,,,,,,125.1,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN PHOSPHOLIPASE A2,3107364,CDM,301,RC,83698,CPT,,,,,,outpatient,facility,,,139,58.38,37.53,133.44,,118.15,,,percent of total billed charges,,,37.53,,,percent of total billed charges,,,95.63,,,percent of total billed charges,,,93.55,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,46.31,,,fee schedule,,,120.93,,,percent of total billed charges,,,120.93,,,percent of total billed charges,,,118.15,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,47.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.1,,,percent of total billed charges,,,46.31,,,fee schedule,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,67.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.52,,,fee schedule,,,41.12,,,fee schedule,,,41.12,,,fee schedule,,,40.3,,,fee schedule,,,46.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",108.56,,,percent of total billed charges,,,126.49,,,percent of total billed charges,,,46.31,,,fee schedule,,,46.31,,,fee schedule,,,41.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA MRSA PRB AMP NS,3107422,CDM,306,RC,87641,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MRSA PRB AMP NS,3107422,CDM,306,RC,87641,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA STREP GROUP B PRB AMP,3107430,CDM,306,RC,87653,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA STREP GROUP B PRB AMP,3107430,CDM,306,RC,87653,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB WEST NILE VIRUS IGM NS,3107489,CDM,302,RC,86788,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB WEST NILE VIRUS IGM NS,3107489,CDM,302,RC,86788,CPT,,,,,,outpatient,facility,,,72,30.24,14.66,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,16.85,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,17.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,16.85,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,24.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.75,,,fee schedule,,,14.96,,,fee schedule,,,14.96,,,fee schedule,,,14.66,,,fee schedule,,,16.85,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,16.85,,,fee schedule,,,16.85,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB WEST NILE VIRUS NS,3107497,CDM,302,RC,86789,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB WEST NILE VIRUS NS,3107497,CDM,302,RC,86789,CPT,,,,,,outpatient,facility,,,72,30.24,12.52,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,14.39,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,14.39,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ ASPRGLS NS,3107505,CDM,306,RC,87305,CPT,,,,,,inpatient,facility,,,152,63.84,129.2,145.92,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.24,,,percent of total billed charges,,,,,,,,,136.8,,,percent of total billed charges,,,145.92,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ ASPRGLS NS,3107505,CDM,306,RC,87305,CPT,,,,,,outpatient,facility,,,152,63.84,10.43,145.92,,129.2,,,percent of total billed charges,,,41.04,,,percent of total billed charges,,,104.58,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,128.44,,,percent of total billed charges,,,11.98,,,fee schedule,,,132.24,,,percent of total billed charges,,,132.24,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,145.92,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",136.8,,,percent of total billed charges,,,11.98,,,fee schedule,,,141.36,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",118.71,,,percent of total billed charges,,,138.32,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN CHOLESTEROL LDL,3107596,CDM,301,RC,83721,CPT,,,,,,inpatient,facility,,,32,13.44,27.2,30.72,,27.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27.84,,,percent of total billed charges,,,,,,,,,28.8,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29.76,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN CHOLESTEROL LDL,3107596,CDM,301,RC,83721,CPT,,,,,,outpatient,facility,,,32,13.44,8.64,30.72,,27.2,,,percent of total billed charges,,,8.64,,,percent of total billed charges,,,22.02,,,percent of total billed charges,,,21.54,,,percent of total billed charges,,,27.04,,,percent of total billed charges,,,10.5,,,fee schedule,,,27.84,,,percent of total billed charges,,,27.84,,,percent of total billed charges,,,27.2,,,percent of total billed charges,,,30.72,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,10.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.8,,,percent of total billed charges,,,10.5,,,fee schedule,,,29.76,,,percent of total billed charges,,,30.4,,,percent of total billed charges,,,15.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.18,,,fee schedule,,,9.32,,,fee schedule,,,9.32,,,fee schedule,,,9.13,,,fee schedule,,,10.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",24.99,,,percent of total billed charges,,,29.12,,,percent of total billed charges,,,10.5,,,fee schedule,,,10.5,,,fee schedule,,,11.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HCG QN NS,3107612,CDM,301,RC,84702,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HCG QN NS,3107612,CDM,301,RC,84702,CPT,,,,,,outpatient,facility,,,67,28.14,13.09,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,15.05,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,15.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,15.05,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,21.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.32,,,fee schedule,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,13.09,,,fee schedule,,,15.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,15.05,,,fee schedule,,,15.05,,,fee schedule,,,18.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT TTL SRM PLASMA BLD WHL NS,3107638,CDM,301,RC,84155,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT TTL SRM PLASMA BLD WHL NS,3107638,CDM,301,RC,84155,CPT,,,,,,outpatient,facility,,,53,22.26,3.19,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,3.67,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,3.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,3.67,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,5.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.95,,,fee schedule,,,3.26,,,fee schedule,,,3.26,,,fee schedule,,,3.19,,,fee schedule,,,3.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,3.67,,,fee schedule,,,3.67,,,fee schedule,,,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT URINE NS,3107646,CDM,301,RC,84156,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT URINE NS,3107646,CDM,301,RC,84156,CPT,,,,,,outpatient,facility,,,59,24.78,3.19,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,3.67,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,3.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,3.67,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,5.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.95,,,fee schedule,,,3.26,,,fee schedule,,,3.26,,,fee schedule,,,3.19,,,fee schedule,,,3.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,3.67,,,fee schedule,,,3.67,,,fee schedule,,,3.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PTT PLASMA BLD WHL NS,3107661,CDM,305,RC,85730,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PTT PLASMA BLD WHL NS,3107661,CDM,305,RC,85730,CPT,,,,,,outpatient,facility,,,54,22.68,5.23,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,6.01,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,6.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,6.01,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,8.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.11,,,fee schedule,,,5.34,,,fee schedule,,,5.34,,,fee schedule,,,5.23,,,fee schedule,,,6.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,6.01,,,fee schedule,,,6.01,,,fee schedule,,,7.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT MIC PLATE EA NS,3107687,CDM,300,RC,87186,CPT,,,,,,inpatient,facility,,,152,63.84,129.2,145.92,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.24,,,percent of total billed charges,,,,,,,,,136.8,,,percent of total billed charges,,,145.92,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,141.36,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT MIC PLATE EA NS,3107687,CDM,300,RC,87186,CPT,,,,,,outpatient,facility,,,152,63.84,7.53,145.92,,129.2,,,percent of total billed charges,,,41.04,,,percent of total billed charges,,,104.58,,,percent of total billed charges,,,102.3,,,percent of total billed charges,,,128.44,,,percent of total billed charges,,,8.65,,,fee schedule,,,132.24,,,percent of total billed charges,,,132.24,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,145.92,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,8.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",136.8,,,percent of total billed charges,,,8.65,,,fee schedule,,,141.36,,,percent of total billed charges,,,144.4,,,percent of total billed charges,,,12.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.68,,,fee schedule,,,7.68,,,fee schedule,,,7.68,,,fee schedule,,,7.53,,,fee schedule,,,8.65,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",118.71,,,percent of total billed charges,,,138.32,,,percent of total billed charges,,,8.65,,,fee schedule,,,8.65,,,fee schedule,,,10.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC UA AUTO WO MICRO,3107695,CDM,307,RC,81003,CPT,,,,,,inpatient,facility,,,7,2.94,5.95,6.72,,5.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.09,,,percent of total billed charges,,,,,,,,,6.3,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC UA AUTO WO MICRO,3107695,CDM,307,RC,81003,CPT,,,,,,outpatient,facility,,,7,2.94,1.89,6.72,,5.95,,,percent of total billed charges,,,1.89,,,percent of total billed charges,,,4.82,,,percent of total billed charges,,,4.71,,,percent of total billed charges,,,5.92,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.09,,,percent of total billed charges,,,6.09,,,percent of total billed charges,,,5.95,,,percent of total billed charges,,,6.72,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,2.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.3,,,percent of total billed charges,,,2.25,,,fee schedule,,,6.51,,,percent of total billed charges,,,6.65,,,percent of total billed charges,,,3.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.04,,,fee schedule,,,2,,,fee schedule,,,2,,,fee schedule,,,1.96,,,fee schedule,,,2.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",5.47,,,percent of total billed charges,,,6.37,,,percent of total billed charges,,,2.25,,,fee schedule,,,2.25,,,fee schedule,,,2.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR PSA,3107745,CDM,301,RC,84153,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR PSA,3107745,CDM,301,RC,84153,CPT,,,,,,outpatient,facility,,,56,23.52,15.12,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,18.39,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,18.39,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,26.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.83,,,fee schedule,,,16.33,,,fee schedule,,,16.33,,,fee schedule,,,16,,,fee schedule,,,18.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,18.39,,,fee schedule,,,18.39,,,fee schedule,,,22.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC BLOOD OCCULT OTHER SOURCE QL,3107786,CDM,301,RC,82271,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC BLOOD OCCULT OTHER SOURCE QL,3107786,CDM,301,RC,82271,CPT,,,,,,outpatient,facility,,,16,6.72,3.99,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.32,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.32,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.18,,,fee schedule,,,4.72,,,fee schedule,,,4.72,,,fee schedule,,,4.63,,,fee schedule,,,5.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.32,,,fee schedule,,,5.32,,,fee schedule,,,3.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA EBV PCR QN,3107828,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA EBV PCR QN,3107828,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IRON TISSUE LIVER,3107836,CDM,301,RC,83540,CPT,,,,,,inpatient,facility,,,208,87.36,176.8,199.68,,176.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.96,,,percent of total billed charges,,,,,,,,,187.2,,,percent of total billed charges,,,199.68,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,193.44,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IRON TISSUE LIVER,3107836,CDM,301,RC,83540,CPT,,,,,,outpatient,facility,,,208,87.36,5.64,199.68,,176.8,,,percent of total billed charges,,,56.16,,,percent of total billed charges,,,143.1,,,percent of total billed charges,,,139.98,,,percent of total billed charges,,,175.76,,,percent of total billed charges,,,6.47,,,fee schedule,,,180.96,,,percent of total billed charges,,,180.96,,,percent of total billed charges,,,176.8,,,percent of total billed charges,,,199.68,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,6.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",187.2,,,percent of total billed charges,,,6.47,,,fee schedule,,,193.44,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,9.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.73,,,fee schedule,,,5.75,,,fee schedule,,,5.75,,,fee schedule,,,5.64,,,fee schedule,,,6.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",162.45,,,percent of total billed charges,,,189.28,,,percent of total billed charges,,,6.47,,,fee schedule,,,6.47,,,fee schedule,,,7.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PRETREAT RBC SEP DENS GRD,3107851,CDM,300,RC,86972,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT RBC SEP DENS GRD,3107851,CDM,300,RC,86972,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT RBC SEP DENS GRD,3107851,CDM,300,RC,86972,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR STAIN FL AFB NS,3107877,CDM,306,RC,87206,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR STAIN FL AFB NS,3107877,CDM,306,RC,87206,CPT,,,,,,outpatient,facility,,,68,28.56,3.01,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,5.39,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,5.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,5.39,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,7.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.28,,,fee schedule,,,4.79,,,fee schedule,,,4.79,,,fee schedule,,,4.69,,,fee schedule,,,5.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,5.39,,,fee schedule,,,5.39,,,fee schedule,,,3.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INHIBITOR VWF PROTEASE,3107893,CDM,305,RC,85335,CPT,,,,,,inpatient,facility,,,225,94.5,191.25,216,,191.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.75,,,percent of total billed charges,,,,,,,,,202.5,,,percent of total billed charges,,,216,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,209.25,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INHIBITOR VWF PROTEASE,3107893,CDM,305,RC,85335,CPT,,,,,,outpatient,facility,,,225,94.5,11.2,216,,191.25,,,percent of total billed charges,,,60.75,,,percent of total billed charges,,,154.8,,,percent of total billed charges,,,151.42,,,percent of total billed charges,,,190.13,,,percent of total billed charges,,,12.87,,,fee schedule,,,195.75,,,percent of total billed charges,,,195.75,,,percent of total billed charges,,,191.25,,,percent of total billed charges,,,216,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,13.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",202.5,,,percent of total billed charges,,,12.87,,,fee schedule,,,209.25,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,18.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.37,,,fee schedule,,,11.43,,,fee schedule,,,11.43,,,fee schedule,,,11.2,,,fee schedule,,,12.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",175.72,,,percent of total billed charges,,,204.75,,,percent of total billed charges,,,12.87,,,fee schedule,,,12.87,,,fee schedule,,,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD RETIC AUTO W PARAM,3107919,CDM,305,RC,85046,CPT,,,,,,inpatient,facility,,,17,7.14,14.45,16.32,,14.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14.79,,,percent of total billed charges,,,,,,,,,15.3,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD RETIC AUTO W PARAM,3107919,CDM,305,RC,85046,CPT,,,,,,outpatient,facility,,,17,7.14,4.59,16.32,,14.45,,,percent of total billed charges,,,4.59,,,percent of total billed charges,,,11.7,,,percent of total billed charges,,,11.44,,,percent of total billed charges,,,14.37,,,percent of total billed charges,,,5.57,,,fee schedule,,,14.79,,,percent of total billed charges,,,14.79,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,16.32,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,5.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.3,,,percent of total billed charges,,,5.57,,,fee schedule,,,15.81,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,8.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.52,,,fee schedule,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,4.85,,,fee schedule,,,5.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",13.28,,,percent of total billed charges,,,15.47,,,percent of total billed charges,,,5.57,,,fee schedule,,,5.57,,,fee schedule,,,6.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
WELLNESS LIPID,3107943,CDM,301,RC,,,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS LIPID,3107943,CDM,301,RC,,,,,,,,outpatient,facility,,,20,8.4,5.4,20,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,20,,,fee schedule,,,20,,,fee schedule,,,20,,,fee schedule,,,,,,,,,15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WELLNESS THYROID,3107950,CDM,301,RC,,,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS THYROID,3107950,CDM,301,RC,,,,,,,,outpatient,facility,,,40,16.8,10.8,40,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,,,,,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,40,,,fee schedule,,,40,,,fee schedule,,,40,,,fee schedule,,,,,,,,,31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WELLNESS TSH,3107976,CDM,301,RC,,,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS TSH,3107976,CDM,301,RC,,,,,,,,outpatient,facility,,,25,10.5,6.75,25,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,,,,,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,25,,,fee schedule,,,25,,,fee schedule,,,25,,,fee schedule,,,,,,,,,19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WELLNESS PSA,3107984,CDM,301,RC,,,,,,,,inpatient,facility,,,30,12.6,25.5,28.8,,25.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,26.1,,,percent of total billed charges,,,,,,,,,27,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS PSA,3107984,CDM,301,RC,,,,,,,,outpatient,facility,,,30,12.6,8.1,30,,25.5,,,percent of total billed charges,,,8.1,,,percent of total billed charges,,,20.64,,,percent of total billed charges,,,20.19,,,percent of total billed charges,,,25.35,,,percent of total billed charges,,,,,,,,,26.1,,,percent of total billed charges,,,26.1,,,percent of total billed charges,,,25.5,,,percent of total billed charges,,,28.8,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,27,,,percent of total billed charges,,,,,,,,,27.9,,,percent of total billed charges,,,28.5,,,percent of total billed charges,,,,,,,,,,,,,,,30,,,fee schedule,,,30,,,fee schedule,,,30,,,fee schedule,,,,,,,,,23.43,,,percent of total billed charges,,,27.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WELLNESS PANEL DIABETES MGMT,3107992,CDM,301,RC,,,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS PANEL DIABETES MGMT,3107992,CDM,301,RC,,,,,,,,outpatient,facility,,,20,8.4,5.4,20,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,20,,,fee schedule,,,20,,,fee schedule,,,20,,,fee schedule,,,,,,,,,15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING PROTEIN S TOTAL NS,3108032,CDM,305,RC,85305,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING PROTEIN S TOTAL NS,3108032,CDM,305,RC,85305,CPT,,,,,,outpatient,facility,,,58,24.36,10.1,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,11.61,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,11.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,11.61,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,16.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.67,,,fee schedule,,,10.31,,,fee schedule,,,10.31,,,fee schedule,,,10.1,,,fee schedule,,,11.61,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,11.61,,,fee schedule,,,11.61,,,fee schedule,,,14.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING PROTEIN S FREE NS,3108040,CDM,305,RC,85306,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING PROTEIN S FREE NS,3108040,CDM,305,RC,85306,CPT,,,,,,outpatient,facility,,,60,25.2,13.33,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,15.32,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,15.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,15.32,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,22.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.68,,,fee schedule,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.33,,,fee schedule,,,15.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,15.32,,,fee schedule,,,15.32,,,fee schedule,,,14.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROID STIMULATING HORMONE NS,3108081,CDM,301,RC,84443,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROID STIMULATING HORMONE NS,3108081,CDM,301,RC,84443,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,16.8,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,17.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,16.8,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,24.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.68,,,fee schedule,,,14.92,,,fee schedule,,,14.92,,,fee schedule,,,14.62,,,fee schedule,,,16.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,16.8,,,fee schedule,,,16.8,,,fee schedule,,,20.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LACTOFERRIN FECAL QL NS,3108123,CDM,301,RC,83630,CPT,,,,,,inpatient,facility,,,98,41.16,83.3,94.08,,83.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.26,,,percent of total billed charges,,,,,,,,,88.2,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LACTOFERRIN FECAL QL NS,3108123,CDM,301,RC,83630,CPT,,,,,,outpatient,facility,,,98,41.16,17.14,94.08,,83.3,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,67.42,,,percent of total billed charges,,,65.95,,,percent of total billed charges,,,82.81,,,percent of total billed charges,,,19.7,,,fee schedule,,,85.26,,,percent of total billed charges,,,85.26,,,percent of total billed charges,,,83.3,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,20.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.2,,,percent of total billed charges,,,19.7,,,fee schedule,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,28.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.6,,,fee schedule,,,17.49,,,fee schedule,,,17.49,,,fee schedule,,,17.14,,,fee schedule,,,19.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",76.54,,,percent of total billed charges,,,89.18,,,percent of total billed charges,,,19.7,,,fee schedule,,,19.7,,,fee schedule,,,24.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PUNCT ARTERIAL FOR DIAGNOSIS,3108149,CDM,300,RC,36600,CPT,,,,,,inpatient,facility,,,349,146.58,296.65,335.04,,296.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,303.63,,,percent of total billed charges,,,,,,,,,314.1,,,percent of total billed charges,,,335.04,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,324.57,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCT ARTERIAL FOR DIAGNOSIS,3108149,CDM,300,RC,36600,CPT,,,,,,outpatient,facility,,,349,146.58,94.23,335.04,,296.65,,,percent of total billed charges,,,94.23,,,percent of total billed charges,,,240.11,,,percent of total billed charges,,,234.88,,,percent of total billed charges,,,294.9,,,percent of total billed charges,,,,,,,,,303.63,,,percent of total billed charges,,,303.63,,,percent of total billed charges,,,296.65,,,percent of total billed charges,,,335.04,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,314.1,,,percent of total billed charges,,,,,,,,,324.57,,,percent of total billed charges,,,331.55,,,percent of total billed charges,,,,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,127.74,,,fee schedule,,,,,,,,,272.57,,,percent of total billed charges,,,317.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCT ARTERIAL FOR DIAGNOSIS,3108149,CDM,300,RC,36600,CPT,5734,APC,,,,outpatient,facility,,,349,349,63.07,189.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,189.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,130.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,63.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PATH GROSS ANDMICRO LVL 5 NS,3108180,CDM,312,RC,88307,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 5 NS,3108180,CDM,312,RC,88307,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 5 NS,3108180,CDM,312,RC,88307,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB STAIN SPECIAL 1 NS,3108198,CDM,312,RC,88312,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB STAIN SPECIAL 1 NS,3108198,CDM,312,RC,88312,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB STAIN SPECIAL 1 NS,3108198,CDM,312,RC,88312,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PATH GROSS ANDMICRO LVL 4 NS,3108271,CDM,312,RC,88305,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 4 NS,3108271,CDM,312,RC,88305,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO LVL 4 NS,3108271,CDM,312,RC,88305,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOM FLOW TECH MARKER 1ST NS,3108305,CDM,311,RC,88184,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOM FLOW TECH MARKER 1ST NS,3108305,CDM,311,RC,88184,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOM FLOW TECH MARKER 1ST NS,3108305,CDM,311,RC,88184,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOM FLOW TECH MARKER ADDL NS,3108313,CDM,311,RC,88185,CPT,,,,,,inpatient,facility,,,126,52.92,107.1,120.96,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.62,,,percent of total billed charges,,,,,,,,,113.4,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOM FLOW TECH MARKER ADDL NS,3108313,CDM,311,RC,88185,CPT,,,,,,outpatient,facility,,,126,52.92,34.02,126,,107.1,,,percent of total billed charges,,,34.02,,,percent of total billed charges,,,86.69,,,percent of total billed charges,,,84.8,,,percent of total billed charges,,,106.47,,,percent of total billed charges,,,,,,,,,109.62,,,percent of total billed charges,,,109.62,,,percent of total billed charges,,,107.1,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,113.4,,,percent of total billed charges,,,,,,,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,126,,,fee schedule,,,126,,,fee schedule,,,126,,,fee schedule,,,,,,,,,98.41,,,percent of total billed charges,,,114.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HANDLING SPECIMEN COMM,3108354,CDM,300,RC,,,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HANDLING SPECIMEN COMM,3108354,CDM,300,RC,,,,,,,,outpatient,facility,,,25,10.5,6.75,25,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,,,,,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,25,,,fee schedule,,,25,,,fee schedule,,,25,,,fee schedule,,,,,,,,,19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PROSTAGLANDIN EA,3108396,CDM,301,RC,84150,CPT,,,,,,inpatient,facility,,,280,117.6,238,268.8,,238,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,243.6,,,percent of total billed charges,,,,,,,,,252,,,percent of total billed charges,,,268.8,,,percent of total billed charges,,,266,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,260.4,,,percent of total billed charges,,,266,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROSTAGLANDIN EA,3108396,CDM,301,RC,84150,CPT,,,,,,outpatient,facility,,,280,117.6,30.61,268.8,,238,,,percent of total billed charges,,,75.6,,,percent of total billed charges,,,192.64,,,percent of total billed charges,,,188.44,,,percent of total billed charges,,,236.6,,,percent of total billed charges,,,41.77,,,fee schedule,,,243.6,,,percent of total billed charges,,,243.6,,,percent of total billed charges,,,238,,,percent of total billed charges,,,268.8,,,percent of total billed charges,,,266,,,percent of total billed charges,,,42.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",252,,,percent of total billed charges,,,41.77,,,fee schedule,,,260.4,,,percent of total billed charges,,,266,,,percent of total billed charges,,,60.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.39,,,fee schedule,,,37.09,,,fee schedule,,,37.09,,,fee schedule,,,36.35,,,fee schedule,,,41.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",218.68,,,percent of total billed charges,,,254.8,,,percent of total billed charges,,,41.77,,,fee schedule,,,41.77,,,fee schedule,,,30.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN PART NO S ANDSBCLS QN,3108404,CDM,301,RC,83704,CPT,,,,,,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN PART NO S ANDSBCLS QN,3108404,CDM,301,RC,83704,CPT,,,,,,outpatient,facility,,,103,43.26,25.74,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,34.19,,,fee schedule,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,34.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",92.7,,,percent of total billed charges,,,34.19,,,fee schedule,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,49.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.16,,,fee schedule,,,30.36,,,fee schedule,,,30.36,,,fee schedule,,,29.75,,,fee schedule,,,34.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,34.19,,,fee schedule,,,34.19,,,fee schedule,,,25.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB MICRO AGG PARTICLE,3108487,CDM,302,RC,86403,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB MICRO AGG PARTICLE,3108487,CDM,302,RC,86403,CPT,,,,,,outpatient,facility,,,62,26.04,10.05,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,11.54,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,11.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,11.54,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,16.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.58,,,fee schedule,,,10.25,,,fee schedule,,,10.25,,,fee schedule,,,10.05,,,fee schedule,,,11.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,11.54,,,fee schedule,,,11.54,,,fee schedule,,,12.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SEMEN SPERM PRESENCE MOTILITY,3108552,CDM,300,RC,89321,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SEMEN SPERM PRESENCE MOTILITY,3108552,CDM,300,RC,89321,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.05,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PANEL METAB BASIC W CA IONIZED,3108586,CDM,301,RC,80047,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PANEL METAB BASIC W CA IONIZED,3108586,CDM,301,RC,80047,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.73,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.73,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,19.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.54,,,fee schedule,,,12.19,,,fee schedule,,,12.19,,,fee schedule,,,11.95,,,fee schedule,,,13.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.73,,,fee schedule,,,13.73,,,fee schedule,,,,,,,,
POC HEMOGLOBIN METHEMOGLOBIN QN,3108628,CDM,301,RC,83050,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC HEMOGLOBIN METHEMOGLOBIN QN,3108628,CDM,301,RC,83050,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.2,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.2,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.07,,,fee schedule,,,7.28,,,fee schedule,,,7.28,,,fee schedule,,,7.13,,,fee schedule,,,8.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.2,,,fee schedule,,,8.2,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALPROTECTIN FECAL,3108651,CDM,301,RC,83993,CPT,,,,,,inpatient,facility,,,250,105,212.5,240,,212.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,217.5,,,percent of total billed charges,,,,,,,,,225,,,percent of total billed charges,,,240,,,percent of total billed charges,,,237.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,232.5,,,percent of total billed charges,,,237.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALPROTECTIN FECAL,3108651,CDM,301,RC,83993,CPT,,,,,,outpatient,facility,,,250,105,17.08,240,,212.5,,,percent of total billed charges,,,67.5,,,percent of total billed charges,,,172,,,percent of total billed charges,,,168.25,,,percent of total billed charges,,,211.25,,,percent of total billed charges,,,19.63,,,fee schedule,,,217.5,,,percent of total billed charges,,,217.5,,,percent of total billed charges,,,212.5,,,percent of total billed charges,,,240,,,percent of total billed charges,,,237.5,,,percent of total billed charges,,,20.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",225,,,percent of total billed charges,,,19.63,,,fee schedule,,,232.5,,,percent of total billed charges,,,237.5,,,percent of total billed charges,,,28.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.5,,,fee schedule,,,17.43,,,fee schedule,,,17.43,,,fee schedule,,,17.08,,,fee schedule,,,19.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",195.25,,,percent of total billed charges,,,227.5,,,percent of total billed charges,,,19.63,,,fee schedule,,,19.63,,,fee schedule,,,24.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM ACHR BLOCKING QN,3108735,CDM,302,RC,86042,CPT,,,,,,inpatient,facility,,,99,41.58,84.15,95.04,,84.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,86.13,,,percent of total billed charges,,,,,,,,,89.1,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,92.07,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM ACHR BLOCKING QN,3108735,CDM,302,RC,86042,CPT,,,,,,outpatient,facility,,,99,41.58,16.01,95.04,,84.15,,,percent of total billed charges,,,26.73,,,percent of total billed charges,,,68.11,,,percent of total billed charges,,,66.63,,,percent of total billed charges,,,83.66,,,percent of total billed charges,,,18.4,,,fee schedule,,,86.13,,,percent of total billed charges,,,86.13,,,percent of total billed charges,,,84.15,,,percent of total billed charges,,,95.04,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,18.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",89.1,,,percent of total billed charges,,,18.4,,,fee schedule,,,92.07,,,percent of total billed charges,,,94.05,,,percent of total billed charges,,,26.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.84,,,fee schedule,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,16.01,,,fee schedule,,,18.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",77.32,,,percent of total billed charges,,,90.09,,,percent of total billed charges,,,18.4,,,fee schedule,,,18.4,,,fee schedule,,,,,,,,
LAB AB PROTOZOA BABESIA,3108768,CDM,302,RC,86753,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB PROTOZOA BABESIA,3108768,CDM,302,RC,86753,CPT,,,,,,outpatient,facility,,,58,24.36,10.78,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,12.39,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,12.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,12.39,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,17.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.73,,,fee schedule,,,11,,,fee schedule,,,11,,,fee schedule,,,10.78,,,fee schedule,,,12.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,12.39,,,fee schedule,,,12.39,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID MYCOPHENOLIC NS,3108792,CDM,301,RC,80180,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID MYCOPHENOLIC NS,3108792,CDM,301,RC,80180,CPT,,,,,,outpatient,facility,,,55,23.1,13.68,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,18.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,18.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.37,,,fee schedule,,,16.03,,,fee schedule,,,16.03,,,fee schedule,,,15.71,,,fee schedule,,,18.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,18.05,,,fee schedule,,,18.05,,,fee schedule,,,13.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACYLCARNITINES QL EA,3108859,CDM,301,RC,82016,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACYLCARNITINES QL EA,3108859,CDM,301,RC,82016,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.49,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.49,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.26,,,fee schedule,,,14.64,,,fee schedule,,,14.64,,,fee schedule,,,14.35,,,fee schedule,,,16.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.49,,,fee schedule,,,16.49,,,fee schedule,,,16.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HERPES 6 PCR QN,3108891,CDM,306,RC,87533,CPT,,,,,,inpatient,facility,,,126,52.92,107.1,120.96,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.62,,,percent of total billed charges,,,,,,,,,113.4,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HERPES 6 PCR QN,3108891,CDM,306,RC,87533,CPT,,,,,,outpatient,facility,,,126,52.92,34.02,120.96,,107.1,,,percent of total billed charges,,,34.02,,,percent of total billed charges,,,86.69,,,percent of total billed charges,,,84.8,,,percent of total billed charges,,,106.47,,,percent of total billed charges,,,41.76,,,fee schedule,,,109.62,,,percent of total billed charges,,,109.62,,,percent of total billed charges,,,107.1,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,42.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",113.4,,,percent of total billed charges,,,41.76,,,fee schedule,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,60.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.38,,,fee schedule,,,37.08,,,fee schedule,,,37.08,,,fee schedule,,,36.34,,,fee schedule,,,41.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",98.41,,,percent of total billed charges,,,114.66,,,percent of total billed charges,,,41.76,,,fee schedule,,,41.76,,,fee schedule,,,51.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA JC VIRUS PCR PRB AMP,3108909,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,123,51.66,104.55,118.08,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.01,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA JC VIRUS PCR PRB AMP,3108909,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,123,51.66,30.54,118.08,,104.55,,,percent of total billed charges,,,33.21,,,percent of total billed charges,,,84.62,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,103.94,,,percent of total billed charges,,,35.09,,,fee schedule,,,107.01,,,percent of total billed charges,,,107.01,,,percent of total billed charges,,,104.55,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",110.7,,,percent of total billed charges,,,35.09,,,fee schedule,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.06,,,percent of total billed charges,,,111.93,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA JC VIRUS PCR QN,3108917,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA JC VIRUS PCR QN,3108917,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA BK VIRUS PCR QN NS,3108925,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA BK VIRUS PCR QN NS,3108925,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VORICONAZOLE,3108933,CDM,301,RC,80285,CPT,,,,,,inpatient,facility,,,127,53.34,107.95,121.92,,107.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.49,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VORICONAZOLE,3108933,CDM,301,RC,80285,CPT,,,,,,outpatient,facility,,,127,53.34,23.59,121.92,,107.95,,,percent of total billed charges,,,34.29,,,percent of total billed charges,,,87.38,,,percent of total billed charges,,,85.47,,,percent of total billed charges,,,107.31,,,percent of total billed charges,,,27.11,,,fee schedule,,,110.49,,,percent of total billed charges,,,110.49,,,percent of total billed charges,,,107.95,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,27.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",114.3,,,percent of total billed charges,,,27.11,,,fee schedule,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,39.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.6,,,fee schedule,,,24.07,,,fee schedule,,,24.07,,,fee schedule,,,23.59,,,fee schedule,,,27.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.19,,,percent of total billed charges,,,115.57,,,percent of total billed charges,,,27.11,,,fee schedule,,,27.11,,,fee schedule,,,,,,,,
LAB AG CARCINOEMBRYONIC NS,3108941,CDM,301,RC,82378,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AG CARCINOEMBRYONIC NS,3108941,CDM,301,RC,82378,CPT,,,,,,outpatient,facility,,,68,28.56,16.5,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,18.96,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,19.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,18.96,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,27.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.6,,,fee schedule,,,16.84,,,fee schedule,,,16.84,,,fee schedule,,,16.5,,,fee schedule,,,18.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,18.96,,,fee schedule,,,18.96,,,fee schedule,,,23.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYSTATIN C,3109022,CDM,301,RC,82610,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYSTATIN C,3109022,CDM,301,RC,82610,CPT,,,,,,outpatient,facility,,,63,26.46,13.56,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,18.52,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,18.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,18.52,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,26.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25,,,fee schedule,,,16.45,,,fee schedule,,,16.45,,,fee schedule,,,16.12,,,fee schedule,,,18.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,18.52,,,fee schedule,,,18.52,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR CULT H PYLORI SGL,3109097,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT H PYLORI SGL,3109097,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,20,8.4,5.16,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.63,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.63,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM CYSTIC FIBROSIS QN,3109154,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM CYSTIC FIBROSIS QN,3109154,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.27,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.27,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INTRP MARROW BONE SMEAR,3109204,CDM,305,RC,85097,CPT,,,,,,inpatient,facility,,,2330,978.6,1980.5,2236.8,,1980.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.1,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INTRP MARROW BONE SMEAR,3109204,CDM,305,RC,85097,CPT,,,,,,outpatient,facility,,,2330,978.6,629.1,2236.8,,1980.5,,,percent of total billed charges,,,629.1,,,percent of total billed charges,,,1603.04,,,percent of total billed charges,,,1568.09,,,percent of total billed charges,,,1968.85,,,percent of total billed charges,,,,,,,,,2027.1,,,percent of total billed charges,,,2027.1,,,percent of total billed charges,,,1980.5,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,859.91,,,fee schedule,,,,,,,,,1819.73,,,percent of total billed charges,,,2120.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB INTRP MARROW BONE SMEAR,3109204,CDM,305,RC,85097,CPT,5674,APC,,,,outpatient,facility,,,2330,2330,421.8,1272.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,895.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,1272.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1184.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,877.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,421.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB DNA STRANDED NATVE DOUBLE NS,3109212,CDM,302,RC,86225,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB DNA STRANDED NATVE DOUBLE NS,3109212,CDM,302,RC,86225,CPT,,,,,,outpatient,facility,,,62,26.04,11.96,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,13.74,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,14.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,13.74,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,19.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.55,,,fee schedule,,,12.2,,,fee schedule,,,12.2,,,fee schedule,,,11.96,,,fee schedule,,,13.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,13.74,,,fee schedule,,,13.74,,,fee schedule,,,16.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG IGE NS,3109287,CDM,301,RC,82785,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG IGE NS,3109287,CDM,301,RC,82785,CPT,,,,,,outpatient,facility,,,58,24.36,14.33,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,16.46,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,16.46,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,23.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.22,,,fee schedule,,,14.62,,,fee schedule,,,14.62,,,fee schedule,,,14.33,,,fee schedule,,,16.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,16.46,,,fee schedule,,,16.46,,,fee schedule,,,20.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GONADOTROPIN LH NS,3109303,CDM,301,RC,83002,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GONADOTROPIN LH NS,3109303,CDM,301,RC,83002,CPT,,,,,,outpatient,facility,,,57,23.94,15.39,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,18.52,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,18.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,18.52,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,26.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25,,,fee schedule,,,16.45,,,fee schedule,,,16.45,,,fee schedule,,,16.12,,,fee schedule,,,18.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,18.52,,,fee schedule,,,18.52,,,fee schedule,,,22.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DEHYDROGENASE G6PD QN NS,3109311,CDM,301,RC,82955,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DEHYDROGENASE G6PD QN NS,3109311,CDM,301,RC,82955,CPT,,,,,,outpatient,facility,,,56,23.52,8.44,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,9.7,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,9.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,9.7,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,14.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.1,,,fee schedule,,,8.61,,,fee schedule,,,8.61,,,fee schedule,,,8.44,,,fee schedule,,,9.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,9.7,,,fee schedule,,,9.7,,,fee schedule,,,11.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANA TITER NS,3109352,CDM,302,RC,86039,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANA TITER NS,3109352,CDM,302,RC,86039,CPT,,,,,,outpatient,facility,,,115,48.3,9.71,110.4,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,11.16,,,fee schedule,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,11.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",103.5,,,percent of total billed charges,,,11.16,,,fee schedule,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,16.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.07,,,fee schedule,,,9.91,,,fee schedule,,,9.91,,,fee schedule,,,9.71,,,fee schedule,,,11.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,11.16,,,fee schedule,,,11.16,,,fee schedule,,,13.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB COCCIDIOIDES NS,3109378,CDM,302,RC,86635,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB COCCIDIOIDES NS,3109378,CDM,302,RC,86635,CPT,,,,,,outpatient,facility,,,66,27.72,5.81,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,11.47,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,11.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,11.47,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,16.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.48,,,fee schedule,,,10.19,,,fee schedule,,,10.19,,,fee schedule,,,9.99,,,fee schedule,,,11.47,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,11.47,,,fee schedule,,,11.47,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TISS NON NEO MARROW BLD NS,3109394,CDM,311,RC,88237,CPT,,,,,,inpatient,facility,,,432,181.44,367.2,414.72,,367.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,375.84,,,percent of total billed charges,,,,,,,,,388.8,,,percent of total billed charges,,,414.72,,,percent of total billed charges,,,410.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,401.76,,,percent of total billed charges,,,410.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TISS NON NEO MARROW BLD NS,3109394,CDM,311,RC,88237,CPT,,,,,,outpatient,facility,,,432,181.44,116.64,414.72,,367.2,,,percent of total billed charges,,,116.64,,,percent of total billed charges,,,297.22,,,percent of total billed charges,,,290.74,,,percent of total billed charges,,,365.04,,,percent of total billed charges,,,143.75,,,fee schedule,,,375.84,,,percent of total billed charges,,,375.84,,,percent of total billed charges,,,367.2,,,percent of total billed charges,,,414.72,,,percent of total billed charges,,,410.4,,,percent of total billed charges,,,146.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",388.8,,,percent of total billed charges,,,143.75,,,fee schedule,,,401.76,,,percent of total billed charges,,,410.4,,,percent of total billed charges,,,208.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",194.06,,,fee schedule,,,127.65,,,fee schedule,,,127.65,,,fee schedule,,,125.1,,,fee schedule,,,143.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",337.39,,,percent of total billed charges,,,393.12,,,percent of total billed charges,,,143.75,,,fee schedule,,,143.75,,,fee schedule,,,154.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SOMATOMEDIN NS,3109428,CDM,301,RC,84305,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SOMATOMEDIN NS,3109428,CDM,301,RC,84305,CPT,,,,,,outpatient,facility,,,64,26.88,17.28,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,21.26,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,21.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,21.26,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,30.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.7,,,fee schedule,,,18.88,,,fee schedule,,,18.88,,,fee schedule,,,18.5,,,fee schedule,,,21.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,21.26,,,fee schedule,,,21.26,,,fee schedule,,,24.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HERPES SIMPLEX TYPE 1 NS,3109444,CDM,302,RC,86695,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HERPES SIMPLEX TYPE 1 NS,3109444,CDM,302,RC,86695,CPT,,,,,,outpatient,facility,,,53,22.26,11.48,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,13.19,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,13.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,13.19,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,19.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.81,,,fee schedule,,,11.71,,,fee schedule,,,11.71,,,fee schedule,,,11.48,,,fee schedule,,,13.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,13.19,,,fee schedule,,,13.19,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FAT LIPIDS FECES QL NS,3109485,CDM,301,RC,82705,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FAT LIPIDS FECES QL NS,3109485,CDM,301,RC,82705,CPT,,,,,,outpatient,facility,,,68,28.56,1.43,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,5.1,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,5.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,5.1,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,7.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.88,,,fee schedule,,,4.53,,,fee schedule,,,4.53,,,fee schedule,,,4.44,,,fee schedule,,,5.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,5.1,,,fee schedule,,,5.1,,,fee schedule,,,1.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ETHYLENE GLYCOL NS,3109493,CDM,301,RC,82693,CPT,,,,,,inpatient,facility,,,94,39.48,79.9,90.24,,79.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,81.78,,,percent of total billed charges,,,,,,,,,84.6,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ETHYLENE GLYCOL NS,3109493,CDM,301,RC,82693,CPT,,,,,,outpatient,facility,,,94,39.48,12.97,90.24,,79.9,,,percent of total billed charges,,,25.38,,,percent of total billed charges,,,64.67,,,percent of total billed charges,,,63.26,,,percent of total billed charges,,,79.43,,,percent of total billed charges,,,14.9,,,fee schedule,,,81.78,,,percent of total billed charges,,,81.78,,,percent of total billed charges,,,79.9,,,percent of total billed charges,,,90.24,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,15.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",84.6,,,percent of total billed charges,,,14.9,,,fee schedule,,,87.42,,,percent of total billed charges,,,89.3,,,percent of total billed charges,,,21.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.12,,,fee schedule,,,13.23,,,fee schedule,,,13.23,,,fee schedule,,,12.97,,,fee schedule,,,14.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",73.41,,,percent of total billed charges,,,85.54,,,percent of total billed charges,,,14.9,,,fee schedule,,,14.9,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ HEP DELTA AGT,3109501,CDM,306,RC,87380,CPT,,,,,,inpatient,facility,,,175,73.5,148.75,168,,148.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,152.25,,,percent of total billed charges,,,,,,,,,157.5,,,percent of total billed charges,,,168,,,percent of total billed charges,,,166.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,162.75,,,percent of total billed charges,,,166.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ HEP DELTA AGT,3109501,CDM,306,RC,87380,CPT,,,,,,outpatient,facility,,,175,73.5,15.97,168,,148.75,,,percent of total billed charges,,,47.25,,,percent of total billed charges,,,120.4,,,percent of total billed charges,,,117.77,,,percent of total billed charges,,,147.88,,,percent of total billed charges,,,18.36,,,fee schedule,,,152.25,,,percent of total billed charges,,,152.25,,,percent of total billed charges,,,148.75,,,percent of total billed charges,,,168,,,percent of total billed charges,,,166.25,,,percent of total billed charges,,,18.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",157.5,,,percent of total billed charges,,,18.36,,,fee schedule,,,162.75,,,percent of total billed charges,,,166.25,,,percent of total billed charges,,,26.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.79,,,fee schedule,,,16.3,,,fee schedule,,,16.3,,,fee schedule,,,15.97,,,fee schedule,,,18.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",136.67,,,percent of total billed charges,,,159.25,,,percent of total billed charges,,,18.36,,,fee schedule,,,18.36,,,fee schedule,,,20.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS B CORE TOTAL NS,3109527,CDM,302,RC,86704,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS B CORE TOTAL NS,3109527,CDM,302,RC,86704,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.05,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,10.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 9 PTC XMAS NS,3109584,CDM,305,RC,85250,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 9 PTC XMAS NS,3109584,CDM,305,RC,85250,CPT,,,,,,outpatient,facility,,,75,31.5,14.02,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,19.04,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,19.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,19.04,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,27.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.7,,,fee schedule,,,16.91,,,fee schedule,,,16.91,,,fee schedule,,,16.57,,,fee schedule,,,19.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,19.04,,,fee schedule,,,19.04,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 11 PTA NS,3109600,CDM,305,RC,85270,CPT,,,,,,inpatient,facility,,,89,37.38,75.65,85.44,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,,,,,,,80.1,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 11 PTA NS,3109600,CDM,305,RC,85270,CPT,,,,,,outpatient,facility,,,89,37.38,14.02,85.44,,75.65,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,61.23,,,percent of total billed charges,,,59.9,,,percent of total billed charges,,,75.2,,,percent of total billed charges,,,17.9,,,fee schedule,,,77.43,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,75.65,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,18.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",80.1,,,percent of total billed charges,,,17.9,,,fee schedule,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,25.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.16,,,fee schedule,,,15.9,,,fee schedule,,,15.9,,,fee schedule,,,15.58,,,fee schedule,,,17.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",69.51,,,percent of total billed charges,,,80.99,,,percent of total billed charges,,,17.9,,,fee schedule,,,17.9,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EBV EBNA NS,3109626,CDM,302,RC,86664,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EBV EBNA NS,3109626,CDM,302,RC,86664,CPT,,,,,,outpatient,facility,,,54,22.68,13.31,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,15.29,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,15.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,15.29,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,22.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.64,,,fee schedule,,,13.58,,,fee schedule,,,13.58,,,fee schedule,,,13.31,,,fee schedule,,,15.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,15.29,,,fee schedule,,,15.29,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB EBV VCA IGM NS,3109642,CDM,302,RC,86665,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB EBV VCA IGM NS,3109642,CDM,302,RC,86665,CPT,,,,,,outpatient,facility,,,55,23.1,14.85,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,18.14,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,18.14,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.49,,,fee schedule,,,16.11,,,fee schedule,,,16.11,,,fee schedule,,,15.79,,,fee schedule,,,18.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,18.14,,,fee schedule,,,18.14,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB VARICELLA ZOSTER IGM NS,3109659,CDM,302,RC,86787,CPT,,,,,,inpatient,facility,,,39,16.38,33.15,37.44,,33.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.93,,,percent of total billed charges,,,,,,,,,35.1,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB VARICELLA ZOSTER IGM NS,3109659,CDM,302,RC,86787,CPT,,,,,,outpatient,facility,,,39,16.38,10.53,37.44,,33.15,,,percent of total billed charges,,,10.53,,,percent of total billed charges,,,26.83,,,percent of total billed charges,,,26.25,,,percent of total billed charges,,,32.95,,,percent of total billed charges,,,12.88,,,fee schedule,,,33.93,,,percent of total billed charges,,,33.93,,,percent of total billed charges,,,33.15,,,percent of total billed charges,,,37.44,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.1,,,percent of total billed charges,,,12.88,,,fee schedule,,,36.27,,,percent of total billed charges,,,37.05,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",30.46,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB VARICELLA ZOSTER IGG NS,3109667,CDM,302,RC,86787,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB VARICELLA ZOSTER IGG NS,3109667,CDM,302,RC,86787,CPT,,,,,,outpatient,facility,,,53,22.26,11.21,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,12.88,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 8 VWF RIST NS,3109675,CDM,305,RC,85245,CPT,,,,,,inpatient,facility,,,87,36.54,73.95,83.52,,73.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.69,,,percent of total billed charges,,,,,,,,,78.3,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,80.91,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 8 VWF RIST NS,3109675,CDM,305,RC,85245,CPT,,,,,,outpatient,facility,,,87,36.54,19.96,83.52,,73.95,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,59.86,,,percent of total billed charges,,,58.55,,,percent of total billed charges,,,73.52,,,percent of total billed charges,,,22.94,,,fee schedule,,,75.69,,,percent of total billed charges,,,75.69,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,23.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",78.3,,,percent of total billed charges,,,22.94,,,fee schedule,,,80.91,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,33.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.97,,,fee schedule,,,20.37,,,fee schedule,,,20.37,,,fee schedule,,,19.96,,,fee schedule,,,22.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",67.95,,,percent of total billed charges,,,79.17,,,percent of total billed charges,,,22.94,,,fee schedule,,,22.94,,,fee schedule,,,28.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHOSPHORUS INORGANIC URINE NS,3109709,CDM,301,RC,84105,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHOSPHORUS INORGANIC URINE NS,3109709,CDM,301,RC,84105,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.78,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.78,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.8,,,fee schedule,,,5.13,,,fee schedule,,,5.13,,,fee schedule,,,5.03,,,fee schedule,,,5.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.78,,,fee schedule,,,5.78,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MAGNESIUM URINE NS,3109717,CDM,301,RC,83735,CPT,,,,,,inpatient,facility,,,21,8.82,17.85,20.16,,17.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18.27,,,percent of total billed charges,,,,,,,,,18.9,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MAGNESIUM URINE NS,3109717,CDM,301,RC,83735,CPT,,,,,,outpatient,facility,,,21,8.82,5.67,20.16,,17.85,,,percent of total billed charges,,,5.67,,,percent of total billed charges,,,14.45,,,percent of total billed charges,,,14.13,,,percent of total billed charges,,,17.75,,,percent of total billed charges,,,6.7,,,fee schedule,,,18.27,,,percent of total billed charges,,,18.27,,,percent of total billed charges,,,17.85,,,percent of total billed charges,,,20.16,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,6.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.9,,,percent of total billed charges,,,6.7,,,fee schedule,,,19.53,,,percent of total billed charges,,,19.95,,,percent of total billed charges,,,9.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.05,,,fee schedule,,,5.95,,,fee schedule,,,5.95,,,fee schedule,,,5.83,,,fee schedule,,,6.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",16.4,,,percent of total billed charges,,,19.11,,,percent of total billed charges,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FACTOR RHEUMATOID QN NS,3109758,CDM,302,RC,86431,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FACTOR RHEUMATOID QN NS,3109758,CDM,302,RC,86431,CPT,,,,,,outpatient,facility,,,55,23.1,4.6,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,5.67,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,5.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,5.67,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,8.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.65,,,fee schedule,,,5.03,,,fee schedule,,,5.03,,,fee schedule,,,4.93,,,fee schedule,,,5.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,5.67,,,fee schedule,,,5.67,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN A NS,3109766,CDM,301,RC,83695,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN A NS,3109766,CDM,301,RC,83695,CPT,,,,,,outpatient,facility,,,58,24.36,12.47,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,14.32,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,14.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,14.32,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,20.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.33,,,fee schedule,,,12.72,,,fee schedule,,,12.72,,,fee schedule,,,12.47,,,fee schedule,,,14.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN FRCTN HR NS,3109832,CDM,301,RC,83701,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN FRCTN HR NS,3109832,CDM,301,RC,83701,CPT,,,,,,outpatient,facility,,,102,42.84,14.02,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,33.86,,,fee schedule,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,34.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",91.8,,,percent of total billed charges,,,33.86,,,fee schedule,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,49.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.71,,,fee schedule,,,30.07,,,fee schedule,,,30.07,,,fee schedule,,,29.47,,,fee schedule,,,33.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,33.86,,,fee schedule,,,33.86,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SYPHILIS VDRL RPR QL ARUP NS,3109865,CDM,302,RC,86592,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SYPHILIS VDRL RPR QL ARUP NS,3109865,CDM,302,RC,86592,CPT,,,,,,outpatient,facility,,,63,26.46,3.62,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,4.27,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,4.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,4.27,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,6.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.76,,,fee schedule,,,3.79,,,fee schedule,,,3.79,,,fee schedule,,,3.71,,,fee schedule,,,4.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,3.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ESTROGEN TOTAL NS,3109956,CDM,301,RC,82672,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ESTROGEN TOTAL NS,3109956,CDM,301,RC,82672,CPT,,,,,,outpatient,facility,,,66,27.72,17.82,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,21.7,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,22.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,21.7,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,31.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.3,,,fee schedule,,,19.27,,,fee schedule,,,19.27,,,fee schedule,,,18.88,,,fee schedule,,,21.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,21.7,,,fee schedule,,,21.7,,,fee schedule,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROGLOBULIN NS,3109980,CDM,301,RC,84432,CPT,,,,,,inpatient,facility,,,57,23.94,48.45,54.72,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,49.59,,,percent of total billed charges,,,,,,,,,51.3,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROGLOBULIN NS,3109980,CDM,301,RC,84432,CPT,,,,,,outpatient,facility,,,57,23.94,13.97,54.72,,48.45,,,percent of total billed charges,,,15.39,,,percent of total billed charges,,,39.22,,,percent of total billed charges,,,38.36,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,16.06,,,fee schedule,,,49.59,,,percent of total billed charges,,,49.59,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,54.72,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,16.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",51.3,,,percent of total billed charges,,,16.06,,,fee schedule,,,53.01,,,percent of total billed charges,,,54.15,,,percent of total billed charges,,,23.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.68,,,fee schedule,,,14.26,,,fee schedule,,,14.26,,,fee schedule,,,13.97,,,fee schedule,,,16.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",44.52,,,percent of total billed charges,,,51.87,,,percent of total billed charges,,,16.06,,,fee schedule,,,16.06,,,fee schedule,,,19.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOTTING FACTOR 13 STB FBR NS,3110038,CDM,305,RC,85290,CPT,,,,,,inpatient,facility,,,98,41.16,83.3,94.08,,83.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.26,,,percent of total billed charges,,,,,,,,,88.2,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOTTING FACTOR 13 STB FBR NS,3110038,CDM,305,RC,85290,CPT,,,,,,outpatient,facility,,,98,41.16,14.22,94.08,,83.3,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,67.42,,,percent of total billed charges,,,65.95,,,percent of total billed charges,,,82.81,,,percent of total billed charges,,,16.34,,,fee schedule,,,85.26,,,percent of total billed charges,,,85.26,,,percent of total billed charges,,,83.3,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,16.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.2,,,percent of total billed charges,,,16.34,,,fee schedule,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,23.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.06,,,fee schedule,,,14.51,,,fee schedule,,,14.51,,,fee schedule,,,14.22,,,fee schedule,,,16.34,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",76.54,,,percent of total billed charges,,,89.18,,,percent of total billed charges,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,20.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PRIMIDONE NS,3110053,CDM,301,RC,80188,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PRIMIDONE NS,3110053,CDM,301,RC,80188,CPT,,,,,,outpatient,facility,,,59,24.78,14.44,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,16.59,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,16.59,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,24.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.4,,,fee schedule,,,14.73,,,fee schedule,,,14.73,,,fee schedule,,,14.44,,,fee schedule,,,16.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,16.59,,,fee schedule,,,16.59,,,fee schedule,,,20.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CRYOFIBRINOGEN NS,3110103,CDM,301,RC,82585,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CRYOFIBRINOGEN NS,3110103,CDM,301,RC,82585,CPT,,,,,,outpatient,facility,,,69,28.98,10.51,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,14.14,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,14.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,14.14,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,20.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.09,,,fee schedule,,,12.56,,,fee schedule,,,12.56,,,fee schedule,,,12.31,,,fee schedule,,,14.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,14.14,,,fee schedule,,,14.14,,,fee schedule,,,10.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB THYROGLOBULIN NS,3110137,CDM,302,RC,86800,CPT,,,,,,inpatient,facility,,,96,40.32,81.6,92.16,,81.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.52,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB THYROGLOBULIN NS,3110137,CDM,302,RC,86800,CPT,,,,,,outpatient,facility,,,96,40.32,13.85,92.16,,81.6,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,81.12,,,percent of total billed charges,,,15.91,,,fee schedule,,,83.52,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,16.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",86.4,,,percent of total billed charges,,,15.91,,,fee schedule,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,23.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.48,,,fee schedule,,,14.13,,,fee schedule,,,14.13,,,fee schedule,,,13.85,,,fee schedule,,,15.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",74.98,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,15.91,,,fee schedule,,,15.91,,,fee schedule,,,19.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NEUTRAL PHOSPHO PLT NS,3110210,CDM,305,RC,85597,CPT,,,,,,inpatient,facility,,,54,22.68,45.9,51.84,,45.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.98,,,percent of total billed charges,,,,,,,,,48.6,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NEUTRAL PHOSPHO PLT NS,3110210,CDM,305,RC,85597,CPT,,,,,,outpatient,facility,,,54,22.68,14.58,51.84,,45.9,,,percent of total billed charges,,,14.58,,,percent of total billed charges,,,37.15,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,17.98,,,fee schedule,,,46.98,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,18.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.6,,,percent of total billed charges,,,17.98,,,fee schedule,,,50.22,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,26.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.27,,,fee schedule,,,15.97,,,fee schedule,,,15.97,,,fee schedule,,,15.65,,,fee schedule,,,17.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.17,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,17.98,,,fee schedule,,,17.98,,,fee schedule,,,18.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC NEUTRALIZATION HEPARIN,3110285,CDM,305,RC,85525,CPT,,,,,,inpatient,facility,,,36,15.12,30.6,34.56,,30.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,31.32,,,percent of total billed charges,,,,,,,,,32.4,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC NEUTRALIZATION HEPARIN,3110285,CDM,305,RC,85525,CPT,,,,,,outpatient,facility,,,36,15.12,9.72,34.56,,30.6,,,percent of total billed charges,,,9.72,,,percent of total billed charges,,,24.77,,,percent of total billed charges,,,24.23,,,percent of total billed charges,,,30.42,,,percent of total billed charges,,,11.84,,,fee schedule,,,31.32,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,30.6,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,12.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.4,,,percent of total billed charges,,,11.84,,,fee schedule,,,33.48,,,percent of total billed charges,,,34.2,,,percent of total billed charges,,,17.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.98,,,fee schedule,,,10.51,,,fee schedule,,,10.51,,,fee schedule,,,10.3,,,fee schedule,,,11.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.12,,,percent of total billed charges,,,32.76,,,percent of total billed charges,,,11.84,,,fee schedule,,,11.84,,,fee schedule,,,14.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC TOLERANCE HEPARIN PROTAMINE,3110293,CDM,305,RC,85530,CPT,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC TOLERANCE HEPARIN PROTAMINE,3110293,CDM,305,RC,85530,CPT,,,,,,outpatient,facility,,,40,16.8,10.8,38.4,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,13.09,,,fee schedule,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,13.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36,,,percent of total billed charges,,,13.09,,,fee schedule,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,18.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.67,,,fee schedule,,,11.62,,,fee schedule,,,11.62,,,fee schedule,,,11.39,,,fee schedule,,,13.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,13.09,,,fee schedule,,,13.09,,,fee schedule,,,17.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MUSK QN,3110301,CDM,302,RC,86366,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MUSK QN,3110301,CDM,302,RC,86366,CPT,,,,,,outpatient,facility,,,56,23.52,15.12,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,18.4,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,18.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,18.4,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,26.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.84,,,fee schedule,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,16.01,,,fee schedule,,,18.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,18.4,,,fee schedule,,,18.4,,,fee schedule,,,,,,,,
LAB SCR AB MUSCLE SMOOTH FL NS,3110319,CDM,302,RC,86015,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB MUSCLE SMOOTH FL NS,3110319,CDM,302,RC,86015,CPT,,,,,,outpatient,facility,,,56,23.52,10.09,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,12.05,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,12.05,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,10.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CRYPTOCOCCUS IFA,3110327,CDM,302,RC,86641,CPT,,,,,,inpatient,facility,,,44,18.48,37.4,42.24,,37.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38.28,,,percent of total billed charges,,,,,,,,,39.6,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CRYPTOCOCCUS IFA,3110327,CDM,302,RC,86641,CPT,,,,,,outpatient,facility,,,44,18.48,11.88,42.24,,37.4,,,percent of total billed charges,,,11.88,,,percent of total billed charges,,,30.27,,,percent of total billed charges,,,29.61,,,percent of total billed charges,,,37.18,,,percent of total billed charges,,,14.41,,,fee schedule,,,38.28,,,percent of total billed charges,,,38.28,,,percent of total billed charges,,,37.4,,,percent of total billed charges,,,42.24,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.6,,,percent of total billed charges,,,14.41,,,fee schedule,,,40.92,,,percent of total billed charges,,,41.8,,,percent of total billed charges,,,20.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.45,,,fee schedule,,,12.8,,,fee schedule,,,12.8,,,fee schedule,,,12.54,,,fee schedule,,,14.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",34.36,,,percent of total billed charges,,,40.04,,,percent of total billed charges,,,14.41,,,fee schedule,,,14.41,,,fee schedule,,,17.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROMIUM,3110517,CDM,301,RC,82495,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMIUM,3110517,CDM,301,RC,82495,CPT,,,,,,outpatient,facility,,,61,25.62,16.47,58.56,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,20.28,,,fee schedule,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,20.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.9,,,percent of total billed charges,,,20.28,,,fee schedule,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,29.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",27.38,,,fee schedule,,,18.01,,,fee schedule,,,18.01,,,fee schedule,,,17.65,,,fee schedule,,,20.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,20.28,,,fee schedule,,,20.28,,,fee schedule,,,19.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM W BND 5 CLL 1 K CVS DIR,3110574,CDM,311,RC,88261,CPT,,,,,,inpatient,facility,,,794,333.48,674.9,762.24,,674.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,690.78,,,percent of total billed charges,,,,,,,,,714.6,,,percent of total billed charges,,,762.24,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,738.42,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM W BND 5 CLL 1 K CVS DIR,3110574,CDM,311,RC,88261,CPT,,,,,,outpatient,facility,,,794,333.48,214.38,762.24,,674.9,,,percent of total billed charges,,,214.38,,,percent of total billed charges,,,546.27,,,percent of total billed charges,,,534.36,,,percent of total billed charges,,,670.93,,,percent of total billed charges,,,264.34,,,fee schedule,,,690.78,,,percent of total billed charges,,,690.78,,,percent of total billed charges,,,674.9,,,percent of total billed charges,,,762.24,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,269.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",714.6,,,percent of total billed charges,,,264.34,,,fee schedule,,,738.42,,,percent of total billed charges,,,754.3,,,percent of total billed charges,,,383.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",356.86,,,fee schedule,,,234.73,,,fee schedule,,,234.73,,,fee schedule,,,230.04,,,fee schedule,,,264.34,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",620.11,,,percent of total billed charges,,,722.54,,,percent of total billed charges,,,264.34,,,fee schedule,,,264.34,,,fee schedule,,,216.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALPHA2 MACROGLOBULIN QN,3110582,CDM,301,RC,83883,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALPHA2 MACROGLOBULIN QN,3110582,CDM,301,RC,83883,CPT,,,,,,outpatient,facility,,,72,30.24,11.84,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,13.6,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,13.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,13.6,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,19.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.36,,,fee schedule,,,12.08,,,fee schedule,,,12.08,,,fee schedule,,,11.84,,,fee schedule,,,13.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM ACHR MODULATING QN,3110590,CDM,302,RC,86043,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM ACHR MODULATING QN,3110590,CDM,302,RC,86043,CPT,,,,,,outpatient,facility,,,78,32.76,10.49,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,12.05,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,12.05,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,,,,,,
LAB ACID MYCOPHENOLIC,3110608,CDM,301,RC,80180,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID MYCOPHENOLIC,3110608,CDM,301,RC,80180,CPT,,,,,,outpatient,facility,,,55,23.1,13.68,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,18.05,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,18.05,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.37,,,fee schedule,,,16.03,,,fee schedule,,,16.03,,,fee schedule,,,15.71,,,fee schedule,,,18.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,18.05,,,fee schedule,,,18.05,,,fee schedule,,,13.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI ID DF YEAST NS,3110723,CDM,306,RC,87106,CPT,,,,,,inpatient,facility,,,136,57.12,115.6,130.56,,115.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.32,,,percent of total billed charges,,,,,,,,,122.4,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI ID DF YEAST NS,3110723,CDM,306,RC,87106,CPT,,,,,,outpatient,facility,,,136,57.12,4.6,130.56,,115.6,,,percent of total billed charges,,,36.72,,,percent of total billed charges,,,93.57,,,percent of total billed charges,,,91.53,,,percent of total billed charges,,,114.92,,,percent of total billed charges,,,10.32,,,fee schedule,,,118.32,,,percent of total billed charges,,,118.32,,,percent of total billed charges,,,115.6,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,10.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",122.4,,,percent of total billed charges,,,10.32,,,fee schedule,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,14.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.93,,,fee schedule,,,9.16,,,fee schedule,,,9.16,,,fee schedule,,,8.98,,,fee schedule,,,10.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",106.22,,,percent of total billed charges,,,123.76,,,percent of total billed charges,,,10.32,,,fee schedule,,,10.32,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT FUNGI ID DF MOLD NS,3110731,CDM,306,RC,87107,CPT,,,,,,inpatient,facility,,,138,57.96,117.3,132.48,,117.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.06,,,percent of total billed charges,,,,,,,,,124.2,,,percent of total billed charges,,,132.48,,,percent of total billed charges,,,131.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,128.34,,,percent of total billed charges,,,131.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT FUNGI ID DF MOLD NS,3110731,CDM,306,RC,87107,CPT,,,,,,outpatient,facility,,,138,57.96,4.6,132.48,,117.3,,,percent of total billed charges,,,37.26,,,percent of total billed charges,,,94.94,,,percent of total billed charges,,,92.87,,,percent of total billed charges,,,116.61,,,percent of total billed charges,,,10.32,,,fee schedule,,,120.06,,,percent of total billed charges,,,120.06,,,percent of total billed charges,,,117.3,,,percent of total billed charges,,,132.48,,,percent of total billed charges,,,131.1,,,percent of total billed charges,,,10.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",124.2,,,percent of total billed charges,,,10.32,,,fee schedule,,,128.34,,,percent of total billed charges,,,131.1,,,percent of total billed charges,,,14.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.93,,,fee schedule,,,9.16,,,fee schedule,,,9.16,,,fee schedule,,,8.98,,,fee schedule,,,10.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",107.78,,,percent of total billed charges,,,125.58,,,percent of total billed charges,,,10.32,,,fee schedule,,,10.32,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT AFB PROPORTION EA NS,3110756,CDM,306,RC,87190,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT AFB PROPORTION EA NS,3110756,CDM,306,RC,87190,CPT,,,,,,outpatient,facility,,,63,26.46,6.36,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,7.31,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,7.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,7.31,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,10.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.87,,,fee schedule,,,6.49,,,fee schedule,,,6.49,,,fee schedule,,,6.36,,,fee schedule,,,7.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,7.31,,,fee schedule,,,7.31,,,fee schedule,,,6.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ELASTASE PANCREATIC FECAL,3110764,CDM,301,RC,82656,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ELASTASE PANCREATIC FECAL,3110764,CDM,301,RC,82656,CPT,,,,,,outpatient,facility,,,104,43.68,10.04,99.84,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,11.53,,,fee schedule,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",93.6,,,percent of total billed charges,,,11.53,,,fee schedule,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA EBV PCR QN NS,3110772,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA EBV PCR QN NS,3110772,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VITAMIN E BETA GAMMA TOCOPHER,3110780,CDM,301,RC,84591,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VITAMIN E BETA GAMMA TOCOPHER,3110780,CDM,301,RC,84591,CPT,,,,,,outpatient,facility,,,52,21.84,12.27,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.06,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.06,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,24.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.03,,,fee schedule,,,15.15,,,fee schedule,,,15.15,,,fee schedule,,,14.85,,,fee schedule,,,17.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.06,,,fee schedule,,,17.06,,,fee schedule,,,12.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA ADENOVIRUS PCR QN,3110798,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA ADENOVIRUS PCR QN,3110798,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HHV NON 6 PCR QN,3110806,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HHV NON 6 PCR QN,3110806,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HHV 8 PCR PRB AMP,3110814,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HHV 8 PCR PRB AMP,3110814,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,124,52.08,30.54,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,35.09,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,35.09,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA EBV PCR PRB AMP,3110822,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA EBV PCR PRB AMP,3110822,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HERPES SIMPLEX TYPE 2 NS,3110830,CDM,302,RC,86696,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HERPES SIMPLEX TYPE 2 NS,3110830,CDM,302,RC,86696,CPT,,,,,,outpatient,facility,,,59,24.78,15.93,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,19.35,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,19.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,19.35,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,28.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.12,,,fee schedule,,,17.18,,,fee schedule,,,17.18,,,fee schedule,,,16.84,,,fee schedule,,,19.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,19.35,,,fee schedule,,,19.35,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COAGULATION ANDFIBRINOLYSIS,3110863,CDM,305,RC,85397,CPT,,,,,,inpatient,facility,,,164,68.88,139.4,157.44,,139.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,142.68,,,percent of total billed charges,,,,,,,,,147.6,,,percent of total billed charges,,,157.44,,,percent of total billed charges,,,155.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,152.52,,,percent of total billed charges,,,155.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COAGULATION ANDFIBRINOLYSIS,3110863,CDM,305,RC,85397,CPT,,,,,,outpatient,facility,,,164,68.88,26.85,157.44,,139.4,,,percent of total billed charges,,,44.28,,,percent of total billed charges,,,112.83,,,percent of total billed charges,,,110.37,,,percent of total billed charges,,,138.58,,,percent of total billed charges,,,30.86,,,fee schedule,,,142.68,,,percent of total billed charges,,,142.68,,,percent of total billed charges,,,139.4,,,percent of total billed charges,,,157.44,,,percent of total billed charges,,,155.8,,,percent of total billed charges,,,31.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",147.6,,,percent of total billed charges,,,30.86,,,fee schedule,,,152.52,,,percent of total billed charges,,,155.8,,,percent of total billed charges,,,44.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.66,,,fee schedule,,,27.4,,,fee schedule,,,27.4,,,fee schedule,,,26.85,,,fee schedule,,,30.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",128.08,,,percent of total billed charges,,,149.24,,,percent of total billed charges,,,30.86,,,fee schedule,,,30.86,,,fee schedule,,,41.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA JO1,3110871,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,123,51.66,104.55,118.08,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.01,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA JO1,3110871,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,123,51.66,15.6,118.08,,104.55,,,percent of total billed charges,,,33.21,,,percent of total billed charges,,,84.62,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,103.94,,,percent of total billed charges,,,17.93,,,fee schedule,,,107.01,,,percent of total billed charges,,,107.01,,,percent of total billed charges,,,104.55,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",110.7,,,percent of total billed charges,,,17.93,,,fee schedule,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.06,,,percent of total billed charges,,,111.93,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS RIBO P PROTEIN QL,3110889,CDM,301,RC,83516,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS RIBO P PROTEIN QL,3110889,CDM,301,RC,83516,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.53,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.53,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA CHROMATIN,3110897,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA CHROMATIN,3110897,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,124,52.08,15.6,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,17.93,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,17.93,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ENA SM RNP,3110905,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA SM RNP,3110905,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,124,52.08,15.6,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,17.93,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,17.93,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB LYME DISEASE IGG IGM,3110921,CDM,302,RC,86618,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB LYME DISEASE IGG IGM,3110921,CDM,302,RC,86618,CPT,,,,,,outpatient,facility,,,66,27.72,14.82,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,17.03,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,17.03,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,24.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.99,,,fee schedule,,,15.12,,,fee schedule,,,15.12,,,fee schedule,,,14.82,,,fee schedule,,,17.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,17.03,,,fee schedule,,,17.03,,,fee schedule,,,20.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB KAPPA LAMBDA LIGHT NS,3110996,CDM,301,RC,83883,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB KAPPA LAMBDA LIGHT NS,3110996,CDM,301,RC,83883,CPT,,,,,,outpatient,facility,,,55,23.1,11.84,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,13.6,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,13.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,13.6,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,19.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.36,,,fee schedule,,,12.08,,,fee schedule,,,12.08,,,fee schedule,,,11.84,,,fee schedule,,,13.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA BK VIRUS PCR PRB AMP,3111002,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA BK VIRUS PCR PRB AMP,3111002,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA CHLAMYD TRAC PRB AMP NS,3111028,CDM,306,RC,87491,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CHLAMYD TRAC PRB AMP NS,3111028,CDM,306,RC,87491,CPT,,,,,,outpatient,facility,,,115,48.3,30.54,110.4,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,35.09,,,fee schedule,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",103.5,,,percent of total billed charges,,,35.09,,,fee schedule,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA GC PRB AMP NS,3111036,CDM,306,RC,87591,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA GC PRB AMP NS,3111036,CDM,306,RC,87591,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB TOXOPLASMA IGM,3111069,CDM,302,RC,86778,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB TOXOPLASMA IGM,3111069,CDM,302,RC,86778,CPT,,,,,,outpatient,facility,,,60,25.2,12.54,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,14.41,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,14.41,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,20.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.45,,,fee schedule,,,12.8,,,fee schedule,,,12.8,,,fee schedule,,,12.54,,,fee schedule,,,14.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,14.41,,,fee schedule,,,14.41,,,fee schedule,,,17.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB TOXOPLASMA IGG,3111077,CDM,302,RC,86777,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB TOXOPLASMA IGG,3111077,CDM,302,RC,86777,CPT,,,,,,outpatient,facility,,,60,25.2,12.52,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,14.39,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,14.39,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB PARAINFLUENZA,3111093,CDM,302,RC,86790,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB PARAINFLUENZA,3111093,CDM,302,RC,86790,CPT,,,,,,outpatient,facility,,,66,27.72,11.21,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,12.88,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,12.88,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB STRONGYLOIDES,3111119,CDM,302,RC,86682,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB STRONGYLOIDES,3111119,CDM,302,RC,86682,CPT,,,,,,outpatient,facility,,,69,28.98,11.32,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,13.01,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,13.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,13.01,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,18.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.56,,,fee schedule,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,11.32,,,fee schedule,,,13.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,13.01,,,fee schedule,,,13.01,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TRIIODOTHYRONINE T3 TOTAL NS,3111168,CDM,301,RC,84480,CPT,,,,,,inpatient,facility,,,43,18.06,36.55,41.28,,36.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,37.41,,,percent of total billed charges,,,,,,,,,38.7,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRIIODOTHYRONINE T3 TOTAL NS,3111168,CDM,301,RC,84480,CPT,,,,,,outpatient,facility,,,43,18.06,11.61,41.28,,36.55,,,percent of total billed charges,,,11.61,,,percent of total billed charges,,,29.58,,,percent of total billed charges,,,28.94,,,percent of total billed charges,,,36.34,,,percent of total billed charges,,,14.18,,,fee schedule,,,37.41,,,percent of total billed charges,,,37.41,,,percent of total billed charges,,,36.55,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,14.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",38.7,,,percent of total billed charges,,,14.18,,,fee schedule,,,39.99,,,percent of total billed charges,,,40.85,,,percent of total billed charges,,,20.56,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.14,,,fee schedule,,,12.59,,,fee schedule,,,12.59,,,fee schedule,,,12.34,,,fee schedule,,,14.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",33.58,,,percent of total billed charges,,,39.13,,,percent of total billed charges,,,14.18,,,fee schedule,,,14.18,,,fee schedule,,,17.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOGLOBIN FRCTN ANDQN CHROMAT NS,3111176,CDM,301,RC,83021,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOGLOBIN FRCTN ANDQN CHROMAT NS,3111176,CDM,301,RC,83021,CPT,,,,,,outpatient,facility,,,55,23.1,14.06,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,18.06,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,18.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,18.06,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,26.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.38,,,fee schedule,,,16.04,,,fee schedule,,,16.04,,,fee schedule,,,15.72,,,fee schedule,,,18.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,18.06,,,fee schedule,,,18.06,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM RIA RECEPTOR TSH QN,3111283,CDM,301,RC,83519,CPT,,,,,,inpatient,facility,,,101,42.42,85.85,96.96,,85.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.87,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM RIA RECEPTOR TSH QN,3111283,CDM,301,RC,83519,CPT,,,,,,outpatient,facility,,,101,42.42,16.01,96.96,,85.85,,,percent of total billed charges,,,27.27,,,percent of total billed charges,,,69.49,,,percent of total billed charges,,,67.97,,,percent of total billed charges,,,85.34,,,percent of total billed charges,,,18.4,,,fee schedule,,,87.87,,,percent of total billed charges,,,87.87,,,percent of total billed charges,,,85.85,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,18.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90.9,,,percent of total billed charges,,,18.4,,,fee schedule,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,26.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.84,,,fee schedule,,,16.34,,,fee schedule,,,16.34,,,fee schedule,,,16.01,,,fee schedule,,,18.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.88,,,percent of total billed charges,,,91.91,,,percent of total billed charges,,,18.4,,,fee schedule,,,18.4,,,fee schedule,,,16.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS HISTONE QL,3111341,CDM,301,RC,83516,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS HISTONE QL,3111341,CDM,301,RC,83516,CPT,,,,,,outpatient,facility,,,62,26.04,10.04,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,11.53,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,11.53,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROM BRK STRS CLASTGN 100 CELL,3111358,CDM,311,RC,88249,CPT,,,,,,inpatient,facility,,,520,218.4,442,499.2,,442,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,452.4,,,percent of total billed charges,,,,,,,,,468,,,percent of total billed charges,,,499.2,,,percent of total billed charges,,,494,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,483.6,,,percent of total billed charges,,,494,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROM BRK STRS CLASTGN 100 CELL,3111358,CDM,311,RC,88249,CPT,,,,,,outpatient,facility,,,520,218.4,140.4,499.2,,442,,,percent of total billed charges,,,140.4,,,percent of total billed charges,,,357.76,,,percent of total billed charges,,,349.96,,,percent of total billed charges,,,439.4,,,percent of total billed charges,,,173.17,,,fee schedule,,,452.4,,,percent of total billed charges,,,452.4,,,percent of total billed charges,,,442,,,percent of total billed charges,,,499.2,,,percent of total billed charges,,,494,,,percent of total billed charges,,,176.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",468,,,percent of total billed charges,,,173.17,,,fee schedule,,,483.6,,,percent of total billed charges,,,494,,,percent of total billed charges,,,251.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",233.78,,,fee schedule,,,153.77,,,fee schedule,,,153.77,,,fee schedule,,,150.69,,,fee schedule,,,173.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",406.12,,,percent of total billed charges,,,473.2,,,percent of total billed charges,,,173.17,,,fee schedule,,,173.17,,,fee schedule,,,212.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB PURKINJE FL,3111390,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB PURKINJE FL,3111390,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,64,26.88,10.49,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,12.05,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,12.05,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AGG PARTICLE TITER STREPTOZYME,3111416,CDM,302,RC,86406,CPT,,,,,,inpatient,facility,,,81,34.02,68.85,77.76,,68.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,70.47,,,percent of total billed charges,,,,,,,,,72.9,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AGG PARTICLE TITER STREPTOZYME,3111416,CDM,302,RC,86406,CPT,,,,,,outpatient,facility,,,81,34.02,9.26,77.76,,68.85,,,percent of total billed charges,,,21.87,,,percent of total billed charges,,,55.73,,,percent of total billed charges,,,54.51,,,percent of total billed charges,,,68.44,,,percent of total billed charges,,,10.64,,,fee schedule,,,70.47,,,percent of total billed charges,,,70.47,,,percent of total billed charges,,,68.85,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,10.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72.9,,,percent of total billed charges,,,10.64,,,fee schedule,,,75.33,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,15.43,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.36,,,fee schedule,,,9.45,,,fee schedule,,,9.45,,,fee schedule,,,9.26,,,fee schedule,,,10.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",63.26,,,percent of total billed charges,,,73.71,,,percent of total billed charges,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,13.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA VZV PCR QN,3111432,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA VZV PCR QN,3111432,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROCALCITONIN,3111630,CDM,301,RC,84145,CPT,,,,,,inpatient,facility,,,141,59.22,119.85,135.36,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROCALCITONIN,3111630,CDM,301,RC,84145,CPT,,,,,,outpatient,facility,,,141,59.22,23.69,135.36,,119.85,,,percent of total billed charges,,,38.07,,,percent of total billed charges,,,97.01,,,percent of total billed charges,,,94.89,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,27.22,,,fee schedule,,,122.67,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,27.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",126.9,,,percent of total billed charges,,,27.22,,,fee schedule,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,39.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.75,,,fee schedule,,,24.17,,,fee schedule,,,24.17,,,fee schedule,,,23.69,,,fee schedule,,,27.22,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",110.12,,,percent of total billed charges,,,128.31,,,percent of total billed charges,,,27.22,,,fee schedule,,,27.22,,,fee schedule,,,24.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FNCT CELL W STIM ANDDET BIOMARK,3111648,CDM,302,RC,86352,CPT,,,,,,inpatient,facility,,,408,171.36,346.8,391.68,,346.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,354.96,,,percent of total billed charges,,,,,,,,,367.2,,,percent of total billed charges,,,391.68,,,percent of total billed charges,,,387.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,379.44,,,percent of total billed charges,,,387.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FNCT CELL W STIM ANDDET BIOMARK,3111648,CDM,302,RC,86352,CPT,,,,,,outpatient,facility,,,408,171.36,85.38,391.68,,346.8,,,percent of total billed charges,,,110.16,,,percent of total billed charges,,,280.7,,,percent of total billed charges,,,274.58,,,percent of total billed charges,,,344.76,,,percent of total billed charges,,,135.86,,,fee schedule,,,354.96,,,percent of total billed charges,,,354.96,,,percent of total billed charges,,,346.8,,,percent of total billed charges,,,391.68,,,percent of total billed charges,,,387.6,,,percent of total billed charges,,,138.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",367.2,,,percent of total billed charges,,,135.86,,,fee schedule,,,379.44,,,percent of total billed charges,,,387.6,,,percent of total billed charges,,,197,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",183.41,,,fee schedule,,,120.64,,,fee schedule,,,120.64,,,fee schedule,,,118.23,,,fee schedule,,,135.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",318.65,,,percent of total billed charges,,,371.28,,,percent of total billed charges,,,135.86,,,fee schedule,,,135.86,,,fee schedule,,,85.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AG CELL MONONUC QN EA AG,3111655,CDM,302,RC,86356,CPT,,,,,,inpatient,facility,,,93,39.06,79.05,89.28,,79.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.91,,,percent of total billed charges,,,,,,,,,83.7,,,percent of total billed charges,,,89.28,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,86.49,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AG CELL MONONUC QN EA AG,3111655,CDM,302,RC,86356,CPT,,,,,,outpatient,facility,,,93,39.06,22.18,89.28,,79.05,,,percent of total billed charges,,,25.11,,,percent of total billed charges,,,63.98,,,percent of total billed charges,,,62.59,,,percent of total billed charges,,,78.58,,,percent of total billed charges,,,26.78,,,fee schedule,,,80.91,,,percent of total billed charges,,,80.91,,,percent of total billed charges,,,79.05,,,percent of total billed charges,,,89.28,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,27.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.7,,,percent of total billed charges,,,26.78,,,fee schedule,,,86.49,,,percent of total billed charges,,,88.35,,,percent of total billed charges,,,38.83,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.15,,,fee schedule,,,23.78,,,fee schedule,,,23.78,,,fee schedule,,,23.3,,,fee schedule,,,26.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",72.63,,,percent of total billed charges,,,84.63,,,percent of total billed charges,,,26.78,,,fee schedule,,,26.78,,,fee schedule,,,22.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ID IG PLATELET ASSOCIATED,3111671,CDM,302,RC,86023,CPT,,,,,,inpatient,facility,,,236,99.12,200.6,226.56,,200.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,205.32,,,percent of total billed charges,,,,,,,,,212.4,,,percent of total billed charges,,,226.56,,,percent of total billed charges,,,224.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,219.48,,,percent of total billed charges,,,224.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ID IG PLATELET ASSOCIATED,3111671,CDM,302,RC,86023,CPT,,,,,,outpatient,facility,,,236,99.12,10.84,226.56,,200.6,,,percent of total billed charges,,,63.72,,,percent of total billed charges,,,162.37,,,percent of total billed charges,,,158.83,,,percent of total billed charges,,,199.42,,,percent of total billed charges,,,12.46,,,fee schedule,,,205.32,,,percent of total billed charges,,,205.32,,,percent of total billed charges,,,200.6,,,percent of total billed charges,,,226.56,,,percent of total billed charges,,,224.2,,,percent of total billed charges,,,12.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",212.4,,,percent of total billed charges,,,12.46,,,fee schedule,,,219.48,,,percent of total billed charges,,,224.2,,,percent of total billed charges,,,18.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.82,,,fee schedule,,,11.06,,,fee schedule,,,11.06,,,fee schedule,,,10.84,,,fee schedule,,,12.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",184.32,,,percent of total billed charges,,,214.76,,,percent of total billed charges,,,12.46,,,fee schedule,,,12.46,,,fee schedule,,,15.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LACTOFERRIN FECAL QN,3111713,CDM,301,RC,83631,CPT,,,,,,inpatient,facility,,,204,85.68,173.4,195.84,,173.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.48,,,percent of total billed charges,,,,,,,,,183.6,,,percent of total billed charges,,,195.84,,,percent of total billed charges,,,193.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,189.72,,,percent of total billed charges,,,193.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LACTOFERRIN FECAL QN,3111713,CDM,301,RC,83631,CPT,,,,,,outpatient,facility,,,204,85.68,17.08,195.84,,173.4,,,percent of total billed charges,,,55.08,,,percent of total billed charges,,,140.35,,,percent of total billed charges,,,137.29,,,percent of total billed charges,,,172.38,,,percent of total billed charges,,,19.63,,,fee schedule,,,177.48,,,percent of total billed charges,,,177.48,,,percent of total billed charges,,,173.4,,,percent of total billed charges,,,195.84,,,percent of total billed charges,,,193.8,,,percent of total billed charges,,,20.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",183.6,,,percent of total billed charges,,,19.63,,,fee schedule,,,189.72,,,percent of total billed charges,,,193.8,,,percent of total billed charges,,,28.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.5,,,fee schedule,,,17.43,,,fee schedule,,,17.43,,,fee schedule,,,17.08,,,fee schedule,,,19.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",159.32,,,percent of total billed charges,,,185.64,,,percent of total billed charges,,,19.63,,,fee schedule,,,19.63,,,fee schedule,,,24.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MCG PROBE DNA PROBE EA NS,3111804,CDM,311,RC,88271,CPT,,,,,,inpatient,facility,,,272,114.24,231.2,261.12,,231.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,236.64,,,percent of total billed charges,,,,,,,,,244.8,,,percent of total billed charges,,,261.12,,,percent of total billed charges,,,258.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,252.96,,,percent of total billed charges,,,258.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MCG PROBE DNA PROBE EA NS,3111804,CDM,311,RC,88271,CPT,,,,,,outpatient,facility,,,272,114.24,18.64,261.12,,231.2,,,percent of total billed charges,,,73.44,,,percent of total billed charges,,,187.14,,,percent of total billed charges,,,183.06,,,percent of total billed charges,,,229.84,,,percent of total billed charges,,,21.42,,,fee schedule,,,236.64,,,percent of total billed charges,,,236.64,,,percent of total billed charges,,,231.2,,,percent of total billed charges,,,261.12,,,percent of total billed charges,,,258.4,,,percent of total billed charges,,,21.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",244.8,,,percent of total billed charges,,,21.42,,,fee schedule,,,252.96,,,percent of total billed charges,,,258.4,,,percent of total billed charges,,,31.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.92,,,fee schedule,,,19.02,,,fee schedule,,,19.02,,,fee schedule,,,18.64,,,fee schedule,,,21.42,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",212.43,,,percent of total billed charges,,,247.52,,,percent of total billed charges,,,21.42,,,fee schedule,,,21.42,,,fee schedule,,,26.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MCG IN SITU INT 100 300 CELL NS,3111812,CDM,311,RC,88275,CPT,,,,,,inpatient,facility,,,154,64.68,130.9,147.84,,130.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.98,,,percent of total billed charges,,,,,,,,,138.6,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MCG IN SITU INT 100 300 CELL NS,3111812,CDM,311,RC,88275,CPT,,,,,,outpatient,facility,,,154,64.68,41.58,147.84,,130.9,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,105.95,,,percent of total billed charges,,,103.64,,,percent of total billed charges,,,130.13,,,percent of total billed charges,,,51.19,,,fee schedule,,,133.98,,,percent of total billed charges,,,133.98,,,percent of total billed charges,,,130.9,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,52.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",138.6,,,percent of total billed charges,,,51.19,,,fee schedule,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,74.23,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.11,,,fee schedule,,,45.46,,,fee schedule,,,45.46,,,fee schedule,,,44.55,,,fee schedule,,,51.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",120.27,,,percent of total billed charges,,,140.14,,,percent of total billed charges,,,51.19,,,fee schedule,,,51.19,,,fee schedule,,,49.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT AFB ID ISOLATES NS,3111838,CDM,306,RC,87116,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT AFB ID ISOLATES NS,3111838,CDM,306,RC,87116,CPT,,,,,,outpatient,facility,,,65,27.3,9.4,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,10.8,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,11.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,10.8,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,15.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.58,,,fee schedule,,,9.59,,,fee schedule,,,9.59,,,fee schedule,,,9.4,,,fee schedule,,,10.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,10.8,,,fee schedule,,,10.8,,,fee schedule,,,13.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD OCCULT FECES 1 3 IMM QL,3111911,CDM,301,RC,82274,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD OCCULT FECES 1 3 IMM QL,3111911,CDM,301,RC,82274,CPT,,,,,,outpatient,facility,,,62,26.04,13.86,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,15.92,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,16.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,15.92,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,23.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.49,,,fee schedule,,,14.14,,,fee schedule,,,14.14,,,fee schedule,,,13.86,,,fee schedule,,,15.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,19.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM RECEPTOR TSH QN,3111929,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM RECEPTOR TSH QN,3111929,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.27,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.27,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB STAIN CONSTITUENTS ENZYME NS,3111952,CDM,312,RC,88319,CPT,,,,,,inpatient,facility,,,2330,978.6,1980.5,2236.8,,1980.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2027.1,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB STAIN CONSTITUENTS ENZYME NS,3111952,CDM,312,RC,88319,CPT,,,,,,outpatient,facility,,,2330,978.6,629.1,2236.8,,1980.5,,,percent of total billed charges,,,629.1,,,percent of total billed charges,,,1603.04,,,percent of total billed charges,,,1568.09,,,percent of total billed charges,,,1968.85,,,percent of total billed charges,,,,,,,,,2027.1,,,percent of total billed charges,,,2027.1,,,percent of total billed charges,,,1980.5,,,percent of total billed charges,,,2236.8,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,2097,,,percent of total billed charges,,,,,,,,,2166.9,,,percent of total billed charges,,,2213.5,,,percent of total billed charges,,,,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,859.91,,,fee schedule,,,,,,,,,1819.73,,,percent of total billed charges,,,2120.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB STAIN CONSTITUENTS ENZYME NS,3111952,CDM,312,RC,88319,CPT,5674,APC,,,,outpatient,facility,,,2330,2330,421.8,1272.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,895.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,877.46,,,fee schedule,,,,,,,,,,,,,,,1272.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1184.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,877.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,877.46,,,fee schedule,,,877.46,,,fee schedule,,,421.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB LEPTOSPIRA TITER,3112026,CDM,302,RC,86720,CPT,,,,,,inpatient,facility,,,154,64.68,130.9,147.84,,130.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.98,,,percent of total billed charges,,,,,,,,,138.6,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB LEPTOSPIRA TITER,3112026,CDM,302,RC,86720,CPT,,,,,,outpatient,facility,,,154,64.68,14.1,147.84,,130.9,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,105.95,,,percent of total billed charges,,,103.64,,,percent of total billed charges,,,130.13,,,percent of total billed charges,,,16.2,,,fee schedule,,,133.98,,,percent of total billed charges,,,133.98,,,percent of total billed charges,,,130.9,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,16.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",138.6,,,percent of total billed charges,,,16.2,,,fee schedule,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,23.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.87,,,fee schedule,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,14.1,,,fee schedule,,,16.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",120.27,,,percent of total billed charges,,,140.14,,,percent of total billed charges,,,16.2,,,fee schedule,,,16.2,,,fee schedule,,,16.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER ANTIMYOCARDIAL,3112034,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,37,15.54,31.45,35.52,,31.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32.19,,,percent of total billed charges,,,,,,,,,33.3,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER ANTIMYOCARDIAL,3112034,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,37,15.54,9.99,35.52,,31.45,,,percent of total billed charges,,,9.99,,,percent of total billed charges,,,25.46,,,percent of total billed charges,,,24.9,,,percent of total billed charges,,,31.27,,,percent of total billed charges,,,12.05,,,fee schedule,,,32.19,,,percent of total billed charges,,,32.19,,,percent of total billed charges,,,31.45,,,percent of total billed charges,,,35.52,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,34.41,,,percent of total billed charges,,,35.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",28.9,,,percent of total billed charges,,,33.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT TOTAL CELLS CD56 NK NS,3112075,CDM,302,RC,86357,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT TOTAL CELLS CD56 NK NS,3112075,CDM,302,RC,86357,CPT,,,,,,outpatient,facility,,,114,47.88,30.78,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,37.73,,,fee schedule,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.6,,,percent of total billed charges,,,37.73,,,fee schedule,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,46.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB QN PNEUMOCOCCAL,3112182,CDM,302,RC,86317,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB QN PNEUMOCOCCAL,3112182,CDM,302,RC,86317,CPT,,,,,,outpatient,facility,,,51,21.42,13.04,48.96,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,14.99,,,fee schedule,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,15.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.9,,,percent of total billed charges,,,14.99,,,fee schedule,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,21.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.24,,,fee schedule,,,13.31,,,fee schedule,,,13.31,,,fee schedule,,,13.04,,,fee schedule,,,14.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,14.99,,,fee schedule,,,14.99,,,fee schedule,,,18.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR HEMOLYSINS ANDAGGLUTININS AUTO,3112208,CDM,302,RC,86940,CPT,,,,,,inpatient,facility,,,490,205.8,416.5,470.4,,416.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.3,,,percent of total billed charges,,,,,,,,,441,,,percent of total billed charges,,,470.4,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,455.7,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR HEMOLYSINS ANDAGGLUTININS AUTO,3112208,CDM,302,RC,86940,CPT,,,,,,outpatient,facility,,,490,205.8,7.33,470.4,,416.5,,,percent of total billed charges,,,132.3,,,percent of total billed charges,,,337.12,,,percent of total billed charges,,,329.77,,,percent of total billed charges,,,414.05,,,percent of total billed charges,,,8.77,,,fee schedule,,,426.3,,,percent of total billed charges,,,426.3,,,percent of total billed charges,,,416.5,,,percent of total billed charges,,,470.4,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,8.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",441,,,percent of total billed charges,,,8.77,,,fee schedule,,,455.7,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,12.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.84,,,fee schedule,,,7.79,,,fee schedule,,,7.79,,,fee schedule,,,7.63,,,fee schedule,,,8.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",382.69,,,percent of total billed charges,,,445.9,,,percent of total billed charges,,,8.77,,,fee schedule,,,8.77,,,fee schedule,,,7.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TB MEAS IMMUNITY GAMMA INTERFRN,3112224,CDM,302,RC,86480,CPT,,,,,,inpatient,facility,,,186,78.12,158.1,178.56,,158.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,161.82,,,percent of total billed charges,,,,,,,,,167.4,,,percent of total billed charges,,,178.56,,,percent of total billed charges,,,176.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.98,,,percent of total billed charges,,,176.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TB MEAS IMMUNITY GAMMA INTERFRN,3112224,CDM,302,RC,86480,CPT,,,,,,outpatient,facility,,,186,78.12,50.22,178.56,,158.1,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,127.97,,,percent of total billed charges,,,125.18,,,percent of total billed charges,,,157.17,,,percent of total billed charges,,,61.98,,,fee schedule,,,161.82,,,percent of total billed charges,,,161.82,,,percent of total billed charges,,,158.1,,,percent of total billed charges,,,178.56,,,percent of total billed charges,,,176.7,,,percent of total billed charges,,,63.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",167.4,,,percent of total billed charges,,,61.98,,,fee schedule,,,172.98,,,percent of total billed charges,,,176.7,,,percent of total billed charges,,,89.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.67,,,fee schedule,,,55.04,,,fee schedule,,,55.04,,,fee schedule,,,53.94,,,fee schedule,,,61.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",145.27,,,percent of total billed charges,,,169.26,,,percent of total billed charges,,,61.98,,,fee schedule,,,61.98,,,fee schedule,,,75.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VITAMIN B 12 CAPACITY BNDG NS,3112232,CDM,301,RC,82608,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VITAMIN B 12 CAPACITY BNDG NS,3112232,CDM,301,RC,82608,CPT,,,,,,outpatient,facility,,,66,27.72,6.99,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,14.32,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,14.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,14.32,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,20.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.33,,,fee schedule,,,12.72,,,fee schedule,,,12.72,,,fee schedule,,,12.47,,,fee schedule,,,14.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,14.32,,,fee schedule,,,14.32,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HEP B QN,3112240,CDM,306,RC,87517,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HEP B QN,3112240,CDM,306,RC,87517,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CARBOXYHEMOGLOBIN QN,3112331,CDM,301,RC,82375,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CARBOXYHEMOGLOBIN QN,3112331,CDM,301,RC,82375,CPT,,,,,,outpatient,facility,,,56,23.52,10.72,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,12.32,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,12.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,12.32,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,17.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.63,,,fee schedule,,,10.94,,,fee schedule,,,10.94,,,fee schedule,,,10.72,,,fee schedule,,,12.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,12.32,,,fee schedule,,,12.32,,,fee schedule,,,15.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING ID SEQ NUC ACID,3112356,CDM,300,RC,87153,CPT,,,,,,inpatient,facility,,,347,145.74,294.95,333.12,,294.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.89,,,percent of total billed charges,,,,,,,,,312.3,,,percent of total billed charges,,,333.12,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,322.71,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING ID SEQ NUC ACID,3112356,CDM,300,RC,87153,CPT,,,,,,outpatient,facility,,,347,145.74,93.69,333.12,,294.95,,,percent of total billed charges,,,93.69,,,percent of total billed charges,,,238.74,,,percent of total billed charges,,,233.53,,,percent of total billed charges,,,293.21,,,percent of total billed charges,,,115.36,,,fee schedule,,,301.89,,,percent of total billed charges,,,301.89,,,percent of total billed charges,,,294.95,,,percent of total billed charges,,,333.12,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,117.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",312.3,,,percent of total billed charges,,,115.36,,,fee schedule,,,322.71,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,167.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",155.74,,,fee schedule,,,102.44,,,fee schedule,,,102.44,,,fee schedule,,,100.39,,,fee schedule,,,115.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",271.01,,,percent of total billed charges,,,315.77,,,percent of total billed charges,,,115.36,,,fee schedule,,,115.36,,,fee schedule,,,144.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA CHLAMYD PNEU PRB AMP NS,3112372,CDM,306,RC,87486,CPT,,,,,,inpatient,facility,,,328,137.76,278.8,314.88,,278.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.36,,,percent of total billed charges,,,,,,,,,295.2,,,percent of total billed charges,,,314.88,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,305.04,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CHLAMYD PNEU PRB AMP NS,3112372,CDM,306,RC,87486,CPT,,,,,,outpatient,facility,,,328,137.76,30.54,314.88,,278.8,,,percent of total billed charges,,,88.56,,,percent of total billed charges,,,225.66,,,percent of total billed charges,,,220.74,,,percent of total billed charges,,,277.16,,,percent of total billed charges,,,35.09,,,fee schedule,,,285.36,,,percent of total billed charges,,,285.36,,,percent of total billed charges,,,278.8,,,percent of total billed charges,,,314.88,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",295.2,,,percent of total billed charges,,,35.09,,,fee schedule,,,305.04,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",256.17,,,percent of total billed charges,,,298.48,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE DONOR SERUM RGT,3112448,CDM,300,RC,86902,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE DONOR SERUM RGT,3112448,CDM,300,RC,86902,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE DONOR SERUM RGT,3112448,CDM,300,RC,86902,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH EVAL FNA IMMED 1ST,3112505,CDM,311,RC,88172,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH EVAL FNA IMMED 1ST,3112505,CDM,311,RC,88172,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH EVAL FNA IMMED 1ST,3112505,CDM,311,RC,88172,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH EVAL FNA IMMED ADDL,3112521,CDM,311,RC,88177,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH EVAL FNA IMMED ADDL,3112521,CDM,311,RC,88177,CPT,,,,,,outpatient,facility,,,90,37.8,24.3,90,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,,,,,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,90,,,fee schedule,,,90,,,fee schedule,,,90,,,fee schedule,,,,,,,,,70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERASE GAMMA GLUTAMYL NS,3112646,CDM,301,RC,82977,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TRANSFERASE GAMMA GLUTAMYL NS,3112646,CDM,301,RC,82977,CPT,,,,,,outpatient,facility,,,62,26.04,6.26,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,7.2,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,7.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,7.2,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,10.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.72,,,fee schedule,,,6.39,,,fee schedule,,,6.39,,,fee schedule,,,6.26,,,fee schedule,,,7.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,7.2,,,fee schedule,,,7.2,,,fee schedule,,,8.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT 4 HUMAN EPIDIDYMIS,3112661,CDM,302,RC,86305,CPT,,,,,,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT 4 HUMAN EPIDIDYMIS,3112661,CDM,302,RC,86305,CPT,,,,,,outpatient,facility,,,97,40.74,18.11,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,20.81,,,fee schedule,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,21.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",87.3,,,percent of total billed charges,,,20.81,,,fee schedule,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,30.17,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.09,,,fee schedule,,,18.48,,,fee schedule,,,18.48,,,fee schedule,,,18.11,,,fee schedule,,,20.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,20.81,,,fee schedule,,,20.81,,,fee schedule,,,26.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC PAMG 1 CERVICOVAGINAL QL,3112679,CDM,301,RC,84112,CPT,,,,,,inpatient,facility,,,295,123.9,250.75,283.2,,250.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.65,,,percent of total billed charges,,,,,,,,,265.5,,,percent of total billed charges,,,283.2,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,274.35,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC PAMG 1 CERVICOVAGINAL QL,3112679,CDM,301,RC,84112,CPT,,,,,,outpatient,facility,,,295,123.9,79.65,283.2,,250.75,,,percent of total billed charges,,,79.65,,,percent of total billed charges,,,202.96,,,percent of total billed charges,,,198.53,,,percent of total billed charges,,,249.28,,,percent of total billed charges,,,98.11,,,fee schedule,,,256.65,,,percent of total billed charges,,,256.65,,,percent of total billed charges,,,250.75,,,percent of total billed charges,,,283.2,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,100.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",265.5,,,percent of total billed charges,,,98.11,,,fee schedule,,,274.35,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,142.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",132.45,,,fee schedule,,,87.12,,,fee schedule,,,87.12,,,fee schedule,,,85.38,,,fee schedule,,,98.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",230.4,,,percent of total billed charges,,,268.45,,,percent of total billed charges,,,98.11,,,fee schedule,,,98.11,,,fee schedule,,,,,,,,
LAB IMM AB GBM QN,3112695,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB GBM QN,3112695,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,60,25.2,15.03,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,17.27,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,17.27,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOTYPE IA HIV 1 TROPISM CORCP,3112703,CDM,306,RC,87906,CPT,,,,,,inpatient,facility,,,387,162.54,328.95,371.52,,328.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,336.69,,,percent of total billed charges,,,,,,,,,348.3,,,percent of total billed charges,,,371.52,,,percent of total billed charges,,,367.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,359.91,,,percent of total billed charges,,,367.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOTYPE IA HIV 1 TROPISM CORCP,3112703,CDM,306,RC,87906,CPT,,,,,,outpatient,facility,,,387,162.54,104.49,371.52,,328.95,,,percent of total billed charges,,,104.49,,,percent of total billed charges,,,266.26,,,percent of total billed charges,,,260.45,,,percent of total billed charges,,,327.01,,,percent of total billed charges,,,128.73,,,fee schedule,,,336.69,,,percent of total billed charges,,,336.69,,,percent of total billed charges,,,328.95,,,percent of total billed charges,,,371.52,,,percent of total billed charges,,,367.65,,,percent of total billed charges,,,131.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",348.3,,,percent of total billed charges,,,128.73,,,fee schedule,,,359.91,,,percent of total billed charges,,,367.65,,,percent of total billed charges,,,186.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",173.79,,,fee schedule,,,114.31,,,fee schedule,,,114.31,,,fee schedule,,,112.02,,,fee schedule,,,128.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",302.25,,,percent of total billed charges,,,352.17,,,percent of total billed charges,,,128.73,,,fee schedule,,,128.73,,,fee schedule,,,,,,,,
LAB ZONISAMIDE,3112711,CDM,301,RC,80203,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ZONISAMIDE,3112711,CDM,301,RC,80203,CPT,,,,,,outpatient,facility,,,79,33.18,11.53,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,13.25,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,13.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,13.25,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,19.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.89,,,fee schedule,,,11.77,,,fee schedule,,,11.77,,,fee schedule,,,11.53,,,fee schedule,,,13.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,13.25,,,fee schedule,,,13.25,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PH FLUID BODY NOS NS,3112737,CDM,301,RC,83986,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PH FLUID BODY NOS NS,3112737,CDM,301,RC,83986,CPT,,,,,,outpatient,facility,,,104,43.68,1.43,99.84,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,3.58,,,fee schedule,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,3.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",93.6,,,percent of total billed charges,,,3.58,,,fee schedule,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,5.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.83,,,fee schedule,,,3.18,,,fee schedule,,,3.18,,,fee schedule,,,3.12,,,fee schedule,,,3.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,3.58,,,fee schedule,,,3.58,,,fee schedule,,,1.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEAVY METAL QN COBALT,3112786,CDM,301,RC,83018,CPT,,,,,,inpatient,facility,,,288,120.96,244.8,276.48,,244.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.56,,,percent of total billed charges,,,,,,,,,259.2,,,percent of total billed charges,,,276.48,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.84,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEAVY METAL QN COBALT,3112786,CDM,301,RC,83018,CPT,,,,,,outpatient,facility,,,288,120.96,19.11,276.48,,244.8,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,198.14,,,percent of total billed charges,,,193.82,,,percent of total billed charges,,,243.36,,,percent of total billed charges,,,21.96,,,fee schedule,,,250.56,,,percent of total billed charges,,,250.56,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,276.48,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,22.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",259.2,,,percent of total billed charges,,,21.96,,,fee schedule,,,267.84,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,31.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.65,,,fee schedule,,,19.5,,,fee schedule,,,19.5,,,fee schedule,,,19.11,,,fee schedule,,,21.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",224.93,,,percent of total billed charges,,,262.08,,,percent of total billed charges,,,21.96,,,fee schedule,,,21.96,,,fee schedule,,,26.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC COAGULATION TIME ACTIVAT TELCOR,3112802,CDM,305,RC,85347,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC COAGULATION TIME ACTIVAT TELCOR,3112802,CDM,305,RC,85347,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.28,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.28,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.78,,,fee schedule,,,3.8,,,fee schedule,,,3.8,,,fee schedule,,,3.72,,,fee schedule,,,4.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.28,,,fee schedule,,,4.28,,,fee schedule,,,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC NITROGEN UREA QN TELCOR,3112810,CDM,301,RC,84520,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC NITROGEN UREA QN TELCOR,3112810,CDM,301,RC,84520,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,11.52,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.95,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.95,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.33,,,fee schedule,,,3.51,,,fee schedule,,,3.51,,,fee schedule,,,3.44,,,fee schedule,,,3.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.95,,,fee schedule,,,3.95,,,fee schedule,,,4.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CREATININE BLOOD TELCOR,3112828,CDM,301,RC,82565,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CREATININE BLOOD TELCOR,3112828,CDM,301,RC,82565,CPT,,,,,,outpatient,facility,,,16,6.72,4.32,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.12,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.12,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.91,,,fee schedule,,,4.55,,,fee schedule,,,4.55,,,fee schedule,,,4.46,,,fee schedule,,,5.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.12,,,fee schedule,,,5.12,,,fee schedule,,,6.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC PROTHROMBIN TIME TELCOR,3112836,CDM,305,RC,85610,CPT,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC PROTHROMBIN TIME TELCOR,3112836,CDM,305,RC,85610,CPT,,,,,,outpatient,facility,,,13,5.46,3.51,12.48,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,4.29,,,fee schedule,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,4.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.7,,,percent of total billed charges,,,4.29,,,fee schedule,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,6.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.79,,,fee schedule,,,3.81,,,fee schedule,,,3.81,,,fee schedule,,,3.73,,,fee schedule,,,4.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.15,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.29,,,fee schedule,,,4.29,,,fee schedule,,,3.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC COUNT BLD HEMATOCRIT TELCOR,3112844,CDM,305,RC,85014,CPT,,,,,,inpatient,facility,,,8,3.36,6.8,7.68,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC COUNT BLD HEMATOCRIT TELCOR,3112844,CDM,305,RC,85014,CPT,,,,,,outpatient,facility,,,8,3.36,2.06,7.68,,6.8,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,2.37,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.2,,,percent of total billed charges,,,2.37,,,fee schedule,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,2.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC COUNT BLD HEMOGLOBIN TELCOR,3112851,CDM,305,RC,85018,CPT,,,,,,inpatient,facility,,,8,3.36,6.8,7.68,,6.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6.96,,,percent of total billed charges,,,,,,,,,7.2,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC COUNT BLD HEMOGLOBIN TELCOR,3112851,CDM,305,RC,85018,CPT,,,,,,outpatient,facility,,,8,3.36,1.95,7.68,,6.8,,,percent of total billed charges,,,2.16,,,percent of total billed charges,,,5.5,,,percent of total billed charges,,,5.38,,,percent of total billed charges,,,6.76,,,percent of total billed charges,,,2.37,,,fee schedule,,,6.96,,,percent of total billed charges,,,6.96,,,percent of total billed charges,,,6.8,,,percent of total billed charges,,,7.68,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.2,,,percent of total billed charges,,,2.37,,,fee schedule,,,7.44,,,percent of total billed charges,,,7.6,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6.25,,,percent of total billed charges,,,7.28,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,1.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC SODIUM SRM PLASMA BLD WHL TLCR,3112869,CDM,301,RC,84295,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC SODIUM SRM PLASMA BLD WHL TLCR,3112869,CDM,301,RC,84295,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.81,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.81,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.49,,,fee schedule,,,4.27,,,fee schedule,,,4.27,,,fee schedule,,,4.18,,,fee schedule,,,4.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.81,,,fee schedule,,,4.81,,,fee schedule,,,5.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC POTASS SRM PLASMA BLD WHL TLCR,3112877,CDM,301,RC,84132,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC POTASS SRM PLASMA BLD WHL TLCR,3112877,CDM,301,RC,84132,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.76,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.76,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.43,,,fee schedule,,,4.23,,,fee schedule,,,4.23,,,fee schedule,,,4.15,,,fee schedule,,,4.76,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.76,,,fee schedule,,,4.76,,,fee schedule,,,5.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CHLORIDE BLOOD TELCOR,3112885,CDM,301,RC,82435,CPT,,,,,,inpatient,facility,,,14,5.88,11.9,13.44,,11.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12.18,,,percent of total billed charges,,,,,,,,,12.6,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CHLORIDE BLOOD TELCOR,3112885,CDM,301,RC,82435,CPT,,,,,,outpatient,facility,,,14,5.88,3.78,13.44,,11.9,,,percent of total billed charges,,,3.78,,,percent of total billed charges,,,9.63,,,percent of total billed charges,,,9.42,,,percent of total billed charges,,,11.83,,,percent of total billed charges,,,4.6,,,fee schedule,,,12.18,,,percent of total billed charges,,,12.18,,,percent of total billed charges,,,11.9,,,percent of total billed charges,,,13.44,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,4.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.6,,,percent of total billed charges,,,4.6,,,fee schedule,,,13.02,,,percent of total billed charges,,,13.3,,,percent of total billed charges,,,6.67,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.21,,,fee schedule,,,4.08,,,fee schedule,,,4.08,,,fee schedule,,,4,,,fee schedule,,,4.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",10.93,,,percent of total billed charges,,,12.74,,,percent of total billed charges,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,5.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC GASES BLD ANY COMBO TELCOR,3112893,CDM,301,RC,82803,CPT,,,,,,inpatient,facility,,,79,33.18,67.15,75.84,,67.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,68.73,,,percent of total billed charges,,,,,,,,,71.1,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GASES BLD ANY COMBO TELCOR,3112893,CDM,301,RC,82803,CPT,,,,,,outpatient,facility,,,79,33.18,21.33,75.84,,67.15,,,percent of total billed charges,,,21.33,,,percent of total billed charges,,,54.35,,,percent of total billed charges,,,53.17,,,percent of total billed charges,,,66.75,,,percent of total billed charges,,,26.07,,,fee schedule,,,68.73,,,percent of total billed charges,,,68.73,,,percent of total billed charges,,,67.15,,,percent of total billed charges,,,75.84,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,26.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",71.1,,,percent of total billed charges,,,26.07,,,fee schedule,,,73.47,,,percent of total billed charges,,,75.05,,,percent of total billed charges,,,37.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",35.19,,,fee schedule,,,23.15,,,fee schedule,,,23.15,,,fee schedule,,,22.69,,,fee schedule,,,26.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",61.7,,,percent of total billed charges,,,71.89,,,percent of total billed charges,,,26.07,,,fee schedule,,,26.07,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC GLUCOSE QN BLOOD TELCOR,3112901,CDM,301,RC,82947,CPT,,,,,,inpatient,facility,,,12,5.04,10.2,11.52,,10.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10.44,,,percent of total billed charges,,,,,,,,,10.8,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GLUCOSE QN BLOOD TELCOR,3112901,CDM,301,RC,82947,CPT,,,,,,outpatient,facility,,,12,5.04,3.24,12,,10.2,,,percent of total billed charges,,,3.24,,,percent of total billed charges,,,8.26,,,percent of total billed charges,,,8.08,,,percent of total billed charges,,,10.14,,,percent of total billed charges,,,3.93,,,fee schedule,,,10.44,,,percent of total billed charges,,,10.44,,,percent of total billed charges,,,10.2,,,percent of total billed charges,,,11.52,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,4.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.8,,,percent of total billed charges,,,3.93,,,fee schedule,,,11.16,,,percent of total billed charges,,,11.4,,,percent of total billed charges,,,5.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.31,,,fee schedule,,,3.49,,,fee schedule,,,3.49,,,fee schedule,,,3.42,,,fee schedule,,,3.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",9.37,,,percent of total billed charges,,,10.92,,,percent of total billed charges,,,3.93,,,fee schedule,,,3.93,,,fee schedule,,,12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC CALCIUM IONIZED TELCOR,3112919,CDM,301,RC,82330,CPT,,,,,,inpatient,facility,,,42,17.64,35.7,40.32,,35.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,36.54,,,percent of total billed charges,,,,,,,,,37.8,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC CALCIUM IONIZED TELCOR,3112919,CDM,301,RC,82330,CPT,,,,,,outpatient,facility,,,42,17.64,11.34,40.32,,35.7,,,percent of total billed charges,,,11.34,,,percent of total billed charges,,,28.9,,,percent of total billed charges,,,28.27,,,percent of total billed charges,,,35.49,,,percent of total billed charges,,,13.68,,,fee schedule,,,36.54,,,percent of total billed charges,,,36.54,,,percent of total billed charges,,,35.7,,,percent of total billed charges,,,40.32,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,13.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.8,,,percent of total billed charges,,,13.68,,,fee schedule,,,39.06,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,19.84,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.47,,,fee schedule,,,12.15,,,fee schedule,,,12.15,,,fee schedule,,,11.91,,,fee schedule,,,13.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",32.8,,,percent of total billed charges,,,38.22,,,percent of total billed charges,,,13.68,,,fee schedule,,,13.68,,,fee schedule,,,16.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC GASES BLD PH ONLY TELCOR,3112927,CDM,301,RC,82800,CPT,,,,,,inpatient,facility,,,33,13.86,28.05,31.68,,28.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28.71,,,percent of total billed charges,,,,,,,,,29.7,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC GASES BLD PH ONLY TELCOR,3112927,CDM,301,RC,82800,CPT,,,,,,outpatient,facility,,,33,13.86,8.91,31.68,,28.05,,,percent of total billed charges,,,8.91,,,percent of total billed charges,,,22.7,,,percent of total billed charges,,,22.21,,,percent of total billed charges,,,27.88,,,percent of total billed charges,,,11,,,fee schedule,,,28.71,,,percent of total billed charges,,,28.71,,,percent of total billed charges,,,28.05,,,percent of total billed charges,,,31.68,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,11.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.7,,,percent of total billed charges,,,11,,,fee schedule,,,30.69,,,percent of total billed charges,,,31.35,,,percent of total billed charges,,,15.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.85,,,fee schedule,,,9.77,,,fee schedule,,,9.77,,,fee schedule,,,9.57,,,fee schedule,,,11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",25.77,,,percent of total billed charges,,,30.03,,,percent of total billed charges,,,11,,,fee schedule,,,11,,,fee schedule,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC PANEL ELECTROLYTE TELCOR,3112935,CDM,301,RC,80051,CPT,,,,,,inpatient,facility,,,22,9.24,18.7,21.12,,18.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19.14,,,percent of total billed charges,,,,,,,,,19.8,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC PANEL ELECTROLYTE TELCOR,3112935,CDM,301,RC,80051,CPT,,,,,,outpatient,facility,,,22,9.24,5.94,21.12,,18.7,,,percent of total billed charges,,,5.94,,,percent of total billed charges,,,15.14,,,percent of total billed charges,,,14.81,,,percent of total billed charges,,,18.59,,,percent of total billed charges,,,7.01,,,fee schedule,,,19.14,,,percent of total billed charges,,,19.14,,,percent of total billed charges,,,18.7,,,percent of total billed charges,,,21.12,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,7.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.8,,,percent of total billed charges,,,7.01,,,fee schedule,,,20.46,,,percent of total billed charges,,,20.9,,,percent of total billed charges,,,10.16,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.46,,,fee schedule,,,6.22,,,fee schedule,,,6.22,,,fee schedule,,,6.1,,,fee schedule,,,7.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",17.18,,,percent of total billed charges,,,20.02,,,percent of total billed charges,,,7.01,,,fee schedule,,,7.01,,,fee schedule,,,7.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC LACTATE LACTIC ACID TELCOR,3112943,CDM,301,RC,83605,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC LACTATE LACTIC ACID TELCOR,3112943,CDM,301,RC,83605,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.57,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.57,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.62,,,fee schedule,,,10.27,,,fee schedule,,,10.27,,,fee schedule,,,10.06,,,fee schedule,,,11.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.57,,,fee schedule,,,11.57,,,fee schedule,,,13.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SEPARATION RED CELL,3112950,CDM,300,RC,86999,CPT,,,,,,inpatient,facility,,,268,112.56,227.8,257.28,,227.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.16,,,percent of total billed charges,,,,,,,,,241.2,,,percent of total billed charges,,,257.28,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,249.24,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SEPARATION RED CELL,3112950,CDM,300,RC,86999,CPT,,,,,,outpatient,facility,,,268,112.56,29.77,257.28,,227.8,,,percent of total billed charges,,,72.36,,,percent of total billed charges,,,184.38,,,percent of total billed charges,,,180.36,,,percent of total billed charges,,,226.46,,,percent of total billed charges,,,,,,,,,233.16,,,percent of total billed charges,,,233.16,,,percent of total billed charges,,,227.8,,,percent of total billed charges,,,257.28,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,,,,,,,241.2,,,percent of total billed charges,,,,,,,,,249.24,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,29.77,,,fee schedule,,,,,,,,,209.31,,,percent of total billed charges,,,243.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB SEPARATION RED CELL,3112950,CDM,300,RC,86999,CPT,5731,APC,,,,outpatient,facility,,,268,268,30.38,187.6,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,30.38,,,fee schedule,,,,,,,,,,,,,,,44.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",41.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,30.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,30.38,,,fee schedule,,,30.38,,,fee schedule,,,187.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ CRYPTOSPOR NS,3112976,CDM,306,RC,87328,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ CRYPTOSPOR NS,3112976,CDM,306,RC,87328,CPT,,,,,,outpatient,facility,,,65,27.3,12.02,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.82,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,14.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.82,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,20.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.66,,,fee schedule,,,12.27,,,fee schedule,,,12.27,,,fee schedule,,,12.02,,,fee schedule,,,13.82,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.82,,,fee schedule,,,13.82,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AGGREGATION PLT CLOPIDOGREL,3112992,CDM,305,RC,85576,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AGGREGATION PLT CLOPIDOGREL,3112992,CDM,305,RC,85576,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,24.91,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,25.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,24.91,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,36.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.63,,,fee schedule,,,22.12,,,fee schedule,,,22.12,,,fee schedule,,,21.68,,,fee schedule,,,24.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,24.91,,,fee schedule,,,24.91,,,fee schedule,,,26.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AGGREGATION PLT ASPIRIN,3113008,CDM,305,RC,85576,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AGGREGATION PLT ASPIRIN,3113008,CDM,305,RC,85576,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,24.91,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,25.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,24.91,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,36.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",33.63,,,fee schedule,,,22.12,,,fee schedule,,,22.12,,,fee schedule,,,21.68,,,fee schedule,,,24.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,24.91,,,fee schedule,,,24.91,,,fee schedule,,,26.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR FIBRINOLYSINS COAG,3113016,CDM,305,RC,85390,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR FIBRINOLYSINS COAG,3113016,CDM,305,RC,85390,CPT,,,,,,outpatient,facility,,,65,27.3,2.06,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,15.48,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,15.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,15.48,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,22.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.9,,,fee schedule,,,13.75,,,fee schedule,,,13.75,,,fee schedule,,,13.48,,,fee schedule,,,15.48,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,15.48,,,fee schedule,,,15.48,,,fee schedule,,,2.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHENOBARBITAL NS,3113032,CDM,301,RC,80184,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHENOBARBITAL NS,3113032,CDM,301,RC,80184,CPT,,,,,,outpatient,facility,,,59,24.78,13.32,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,15.3,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,15.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,15.3,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,22.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.66,,,fee schedule,,,13.59,,,fee schedule,,,13.59,,,fee schedule,,,13.32,,,fee schedule,,,15.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,15.3,,,fee schedule,,,15.3,,,fee schedule,,,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHOSPHORUS INORGANIC NS,3113057,CDM,301,RC,84100,CPT,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHOSPHORUS INORGANIC NS,3113057,CDM,301,RC,84100,CPT,,,,,,outpatient,facility,,,15,6.3,4.05,14.4,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,4.74,,,fee schedule,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,4.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.5,,,percent of total billed charges,,,4.74,,,fee schedule,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,6.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.4,,,fee schedule,,,4.21,,,fee schedule,,,4.21,,,fee schedule,,,4.13,,,fee schedule,,,4.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,4.74,,,fee schedule,,,4.74,,,fee schedule,,,5.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC STOOL PATH NS,3113073,CDM,306,RC,87046,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC STOOL PATH NS,3113073,CDM,306,RC,87046,CPT,,,,,,outpatient,facility,,,63,26.46,4.6,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,9.44,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,9.44,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,4.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING ID NUC ACID PRB AMP,3113081,CDM,306,RC,87150,CPT,,,,,,inpatient,facility,,,137,57.54,116.45,131.52,,116.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.19,,,percent of total billed charges,,,,,,,,,123.3,,,percent of total billed charges,,,131.52,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.41,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING ID NUC ACID PRB AMP,3113081,CDM,306,RC,87150,CPT,,,,,,outpatient,facility,,,137,57.54,30.54,131.52,,116.45,,,percent of total billed charges,,,36.99,,,percent of total billed charges,,,94.26,,,percent of total billed charges,,,92.2,,,percent of total billed charges,,,115.77,,,percent of total billed charges,,,35.09,,,fee schedule,,,119.19,,,percent of total billed charges,,,119.19,,,percent of total billed charges,,,116.45,,,percent of total billed charges,,,131.52,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",123.3,,,percent of total billed charges,,,35.09,,,fee schedule,,,127.41,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",107,,,percent of total billed charges,,,124.67,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,44.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA BK VIRUS PCR QN URINE,3113115,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA BK VIRUS PCR QN URINE,3113115,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT WB W INTRP ID CREUTZ JAKOB,3113131,CDM,301,RC,84182,CPT,,,,,,inpatient,facility,,,89,37.38,75.65,85.44,,75.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.43,,,percent of total billed charges,,,,,,,,,80.1,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT WB W INTRP ID CREUTZ JAKOB,3113131,CDM,301,RC,84182,CPT,,,,,,outpatient,facility,,,89,37.38,22.06,85.44,,75.65,,,percent of total billed charges,,,24.03,,,percent of total billed charges,,,61.23,,,percent of total billed charges,,,59.9,,,percent of total billed charges,,,75.2,,,percent of total billed charges,,,29.21,,,fee schedule,,,77.43,,,percent of total billed charges,,,77.43,,,percent of total billed charges,,,75.65,,,percent of total billed charges,,,85.44,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,29.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",80.1,,,percent of total billed charges,,,29.21,,,fee schedule,,,82.77,,,percent of total billed charges,,,84.55,,,percent of total billed charges,,,42.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.43,,,fee schedule,,,25.94,,,fee schedule,,,25.94,,,fee schedule,,,25.42,,,fee schedule,,,29.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",69.51,,,percent of total billed charges,,,80.99,,,percent of total billed charges,,,29.21,,,fee schedule,,,29.21,,,fee schedule,,,22.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB QN CREUTZFELDT JAKOB,3113149,CDM,302,RC,86317,CPT,,,,,,inpatient,facility,,,83,34.86,70.55,79.68,,70.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.21,,,percent of total billed charges,,,,,,,,,74.7,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB QN CREUTZFELDT JAKOB,3113149,CDM,302,RC,86317,CPT,,,,,,outpatient,facility,,,83,34.86,13.04,79.68,,70.55,,,percent of total billed charges,,,22.41,,,percent of total billed charges,,,57.1,,,percent of total billed charges,,,55.86,,,percent of total billed charges,,,70.13,,,percent of total billed charges,,,14.99,,,fee schedule,,,72.21,,,percent of total billed charges,,,72.21,,,percent of total billed charges,,,70.55,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,15.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.7,,,percent of total billed charges,,,14.99,,,fee schedule,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,21.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.24,,,fee schedule,,,13.31,,,fee schedule,,,13.31,,,fee schedule,,,13.04,,,fee schedule,,,14.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.82,,,percent of total billed charges,,,75.53,,,percent of total billed charges,,,14.99,,,fee schedule,,,14.99,,,fee schedule,,,18.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SPCTPHOT 1 3 BETA D GLUCAN,3113156,CDM,301,RC,84311,CPT,,,,,,inpatient,facility,,,157,65.94,133.45,150.72,,133.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.59,,,percent of total billed charges,,,,,,,,,141.3,,,percent of total billed charges,,,150.72,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.01,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SPCTPHOT 1 3 BETA D GLUCAN,3113156,CDM,301,RC,84311,CPT,,,,,,outpatient,facility,,,157,65.94,7.05,150.72,,133.45,,,percent of total billed charges,,,42.39,,,percent of total billed charges,,,108.02,,,percent of total billed charges,,,105.66,,,percent of total billed charges,,,132.66,,,percent of total billed charges,,,8.1,,,fee schedule,,,136.59,,,percent of total billed charges,,,136.59,,,percent of total billed charges,,,133.45,,,percent of total billed charges,,,150.72,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,8.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",141.3,,,percent of total billed charges,,,8.1,,,fee schedule,,,146.01,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,11.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.94,,,fee schedule,,,7.19,,,fee schedule,,,7.19,,,fee schedule,,,7.05,,,fee schedule,,,8.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",122.62,,,percent of total billed charges,,,142.87,,,percent of total billed charges,,,8.1,,,fee schedule,,,8.1,,,fee schedule,,,8.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HEMOGLOBIN METHEMOGLOBIN QN,3113214,CDM,301,RC,83050,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HEMOGLOBIN METHEMOGLOBIN QN,3113214,CDM,301,RC,83050,CPT,,,,,,outpatient,facility,,,59,24.78,6.99,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,8.2,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,8.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,8.2,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.07,,,fee schedule,,,7.28,,,fee schedule,,,7.28,,,fee schedule,,,7.13,,,fee schedule,,,8.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,8.2,,,fee schedule,,,8.2,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA TOXOPLASMA PCR QN,3113222,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,130,54.6,110.5,124.8,,110.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.1,,,percent of total billed charges,,,,,,,,,117,,,percent of total billed charges,,,124.8,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.9,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA TOXOPLASMA PCR QN,3113222,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,130,54.6,35.1,124.8,,110.5,,,percent of total billed charges,,,35.1,,,percent of total billed charges,,,89.44,,,percent of total billed charges,,,87.49,,,percent of total billed charges,,,109.85,,,percent of total billed charges,,,42.84,,,fee schedule,,,113.1,,,percent of total billed charges,,,113.1,,,percent of total billed charges,,,110.5,,,percent of total billed charges,,,124.8,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",117,,,percent of total billed charges,,,42.84,,,fee schedule,,,120.9,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",101.53,,,percent of total billed charges,,,118.3,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA PNEUMOCYSTIS PCR QN,3113230,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,275,115.5,233.75,264,,233.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.25,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA PNEUMOCYSTIS PCR QN,3113230,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,275,115.5,37.28,264,,233.75,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,189.2,,,percent of total billed charges,,,185.07,,,percent of total billed charges,,,232.38,,,percent of total billed charges,,,42.84,,,fee schedule,,,239.25,,,percent of total billed charges,,,239.25,,,percent of total billed charges,,,233.75,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",247.5,,,percent of total billed charges,,,42.84,,,fee schedule,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",214.78,,,percent of total billed charges,,,250.25,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS NEUROMYLTS OPT IGG QL,3113248,CDM,301,RC,83516,CPT,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS NEUROMYLTS OPT IGG QL,3113248,CDM,301,RC,83516,CPT,,,,,,outpatient,facility,,,35,14.7,9.45,33.6,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,11.53,,,fee schedule,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.5,,,percent of total billed charges,,,11.53,,,fee schedule,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ ENTAM HIST NS,3113255,CDM,306,RC,87337,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ ENTAM HIST NS,3113255,CDM,306,RC,87337,CPT,,,,,,outpatient,facility,,,73,30.66,10.43,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,11.98,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,11.98,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TB MEAS IMMUNITY T CELL SUSP,3113362,CDM,302,RC,86481,CPT,,,,,,inpatient,facility,,,300,126,255,288,,255,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TB MEAS IMMUNITY T CELL SUSP,3113362,CDM,302,RC,86481,CPT,,,,,,outpatient,facility,,,300,126,81,288,,255,,,percent of total billed charges,,,81,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,201.9,,,percent of total billed charges,,,253.5,,,percent of total billed charges,,,100,,,fee schedule,,,261,,,percent of total billed charges,,,261,,,percent of total billed charges,,,255,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,102,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",270,,,percent of total billed charges,,,100,,,fee schedule,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,145,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",135,,,fee schedule,,,88.8,,,fee schedule,,,88.8,,,fee schedule,,,87.02,,,fee schedule,,,100,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",234.3,,,percent of total billed charges,,,273,,,percent of total billed charges,,,100,,,fee schedule,,,100,,,fee schedule,,,,,,,,
LAB PRETREAT SERUM INCUB INHIB,3113370,CDM,302,RC,86977,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM INCUB INHIB,3113370,CDM,302,RC,86977,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM INCUB INHIB,3113370,CDM,302,RC,86977,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA PARVOVIRUS PCR QN,3113420,CDM,306,RC,87799,CPT,,,,,,inpatient,facility,,,141,59.22,119.85,135.36,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA PARVOVIRUS PCR QN,3113420,CDM,306,RC,87799,CPT,,,,,,outpatient,facility,,,141,59.22,37.28,135.36,,119.85,,,percent of total billed charges,,,38.07,,,percent of total billed charges,,,97.01,,,percent of total billed charges,,,94.89,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,42.84,,,fee schedule,,,122.67,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",126.9,,,percent of total billed charges,,,42.84,,,fee schedule,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",110.12,,,percent of total billed charges,,,128.31,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ STREP PNEU QL,3113446,CDM,306,RC,87449,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ STREP PNEU QL,3113446,CDM,306,RC,87449,CPT,,,,,,outpatient,facility,,,65,27.3,10.43,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,11.98,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,11.98,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA TOXIN C DIFF PRB AMP,3113461,CDM,306,RC,87493,CPT,,,,,,inpatient,facility,,,112,47.04,95.2,107.52,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA TOXIN C DIFF PRB AMP,3113461,CDM,306,RC,87493,CPT,,,,,,outpatient,facility,,,112,47.04,30.24,107.52,,95.2,,,percent of total billed charges,,,30.24,,,percent of total billed charges,,,77.06,,,percent of total billed charges,,,75.38,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,37.27,,,fee schedule,,,97.44,,,percent of total billed charges,,,97.44,,,percent of total billed charges,,,95.2,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,38.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.8,,,percent of total billed charges,,,37.27,,,fee schedule,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,54.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.31,,,fee schedule,,,33.1,,,fee schedule,,,33.1,,,fee schedule,,,32.44,,,fee schedule,,,37.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",87.47,,,percent of total billed charges,,,101.92,,,percent of total billed charges,,,37.27,,,fee schedule,,,37.27,,,fee schedule,,,44.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS GLIADIN QL,3113479,CDM,302,RC,86258,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS GLIADIN QL,3113479,CDM,302,RC,86258,CPT,,,,,,outpatient,facility,,,59,24.78,10.49,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,12.05,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,12.05,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,11.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS TRANSGLUTAMINASE QL,3113487,CDM,302,RC,86364,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS TRANSGLUTAMINASE QL,3113487,CDM,302,RC,86364,CPT,,,,,,outpatient,facility,,,59,24.78,10.04,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,11.53,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,11.53,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,10.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB FL TITER NS,3113495,CDM,302,RC,86256,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB FL TITER NS,3113495,CDM,302,RC,86256,CPT,,,,,,outpatient,facility,,,78,32.76,10.49,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,12.05,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,12.05,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CYTOPATH URIN MANUAL PRB 3 5 EA,3113511,CDM,311,RC,88120,CPT,,,,,,inpatient,facility,,,1181,496.02,1003.85,1133.76,,1003.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.47,,,percent of total billed charges,,,,,,,,,1062.9,,,percent of total billed charges,,,1133.76,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1098.33,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH URIN MANUAL PRB 3 5 EA,3113511,CDM,311,RC,88120,CPT,,,,,,outpatient,facility,,,1181,496.02,170.8,1133.76,,1003.85,,,percent of total billed charges,,,318.87,,,percent of total billed charges,,,812.53,,,percent of total billed charges,,,794.81,,,percent of total billed charges,,,997.94,,,percent of total billed charges,,,,,,,,,1027.47,,,percent of total billed charges,,,1027.47,,,percent of total billed charges,,,1003.85,,,percent of total billed charges,,,1133.76,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,1062.9,,,percent of total billed charges,,,,,,,,,1098.33,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,922.36,,,percent of total billed charges,,,1074.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CYTOPATH URIN MANUAL PRB 3 5 EA,3113511,CDM,311,RC,88120,CPT,5672,APC,,,,outpatient,facility,,,1181,1181,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PYRUVATE KINASE NS,3113537,CDM,301,RC,84220,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PYRUVATE KINASE NS,3113537,CDM,301,RC,84220,CPT,,,,,,outpatient,facility,,,187,78.54,8.21,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,9.44,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,9.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,9.44,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,13.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.74,,,fee schedule,,,8.38,,,fee schedule,,,8.38,,,fee schedule,,,8.21,,,fee schedule,,,9.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,9.44,,,fee schedule,,,9.44,,,fee schedule,,,10.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT TOTAL CELLS T NS,3113545,CDM,302,RC,86359,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT TOTAL CELLS T NS,3113545,CDM,302,RC,86359,CPT,,,,,,outpatient,facility,,,114,47.88,30.78,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,37.73,,,fee schedule,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.6,,,percent of total billed charges,,,37.73,,,fee schedule,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,46.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT CELLS T CD4 ANDCD8 RATIO NS,3113552,CDM,302,RC,86360,CPT,,,,,,inpatient,facility,,,141,59.22,119.85,135.36,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT CELLS T CD4 ANDCD8 RATIO NS,3113552,CDM,302,RC,86360,CPT,,,,,,outpatient,facility,,,141,59.22,38.07,135.36,,119.85,,,percent of total billed charges,,,38.07,,,percent of total billed charges,,,97.01,,,percent of total billed charges,,,94.89,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,46.98,,,fee schedule,,,122.67,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,47.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",126.9,,,percent of total billed charges,,,46.98,,,fee schedule,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,68.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.42,,,fee schedule,,,41.72,,,fee schedule,,,41.72,,,fee schedule,,,40.89,,,fee schedule,,,46.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",110.12,,,percent of total billed charges,,,128.31,,,percent of total billed charges,,,46.98,,,fee schedule,,,46.98,,,fee schedule,,,57.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE IMMUNOPHENOTYPE,3113610,CDM,300,RC,86905,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE IMMUNOPHENOTYPE,3113610,CDM,300,RC,86905,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE IMMUNOPHENOTYPE,3113610,CDM,300,RC,86905,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BLOOD TYPE DONOR SERUM RGT NS,3113628,CDM,300,RC,86902,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE DONOR SERUM RGT NS,3113628,CDM,300,RC,86902,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB BLOOD TYPE DONOR SERUM RGT NS,3113628,CDM,300,RC,86902,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MICRODISSECTION MANUAL,3113644,CDM,312,RC,88381,CPT,,,,,,inpatient,facility,,,230,96.6,195.5,220.8,,195.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.1,,,percent of total billed charges,,,,,,,,,207,,,percent of total billed charges,,,220.8,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,213.9,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MICRODISSECTION MANUAL,3113644,CDM,312,RC,88381,CPT,,,,,,outpatient,facility,,,230,96.6,62.1,230,,195.5,,,percent of total billed charges,,,62.1,,,percent of total billed charges,,,158.24,,,percent of total billed charges,,,154.79,,,percent of total billed charges,,,194.35,,,percent of total billed charges,,,,,,,,,200.1,,,percent of total billed charges,,,200.1,,,percent of total billed charges,,,195.5,,,percent of total billed charges,,,220.8,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,207,,,percent of total billed charges,,,,,,,,,213.9,,,percent of total billed charges,,,218.5,,,percent of total billed charges,,,,,,,,,,,,,,,230,,,fee schedule,,,230,,,fee schedule,,,230,,,fee schedule,,,,,,,,,179.63,,,percent of total billed charges,,,209.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PLATELET RETICULATED,3113685,CDM,305,RC,85055,CPT,,,,,,inpatient,facility,,,108,45.36,91.8,103.68,,91.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.96,,,percent of total billed charges,,,,,,,,,97.2,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PLATELET RETICULATED,3113685,CDM,305,RC,85055,CPT,,,,,,outpatient,facility,,,108,45.36,22.18,103.68,,91.8,,,percent of total billed charges,,,29.16,,,percent of total billed charges,,,74.3,,,percent of total billed charges,,,72.68,,,percent of total billed charges,,,91.26,,,percent of total billed charges,,,35.74,,,fee schedule,,,93.96,,,percent of total billed charges,,,93.96,,,percent of total billed charges,,,91.8,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,36.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.2,,,percent of total billed charges,,,35.74,,,fee schedule,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,51.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",48.25,,,fee schedule,,,31.74,,,fee schedule,,,31.74,,,fee schedule,,,31.11,,,fee schedule,,,35.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",84.35,,,percent of total billed charges,,,98.28,,,percent of total billed charges,,,35.74,,,fee schedule,,,35.74,,,fee schedule,,,22.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PRETREAT SERUM INCUB W DRUGS,3113727,CDM,302,RC,86975,CPT,,,,,,inpatient,facility,,,1139,478.38,968.15,1093.44,,968.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,990.93,,,percent of total billed charges,,,,,,,,,1025.1,,,percent of total billed charges,,,1093.44,,,percent of total billed charges,,,1082.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1059.27,,,percent of total billed charges,,,1082.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM INCUB W DRUGS,3113727,CDM,302,RC,86975,CPT,,,,,,outpatient,facility,,,1139,478.38,307.53,1093.44,,968.15,,,percent of total billed charges,,,307.53,,,percent of total billed charges,,,783.63,,,percent of total billed charges,,,766.55,,,percent of total billed charges,,,962.45,,,percent of total billed charges,,,,,,,,,990.93,,,percent of total billed charges,,,990.93,,,percent of total billed charges,,,968.15,,,percent of total billed charges,,,1093.44,,,percent of total billed charges,,,1082.05,,,percent of total billed charges,,,,,,,,,1025.1,,,percent of total billed charges,,,,,,,,,1059.27,,,percent of total billed charges,,,1082.05,,,percent of total billed charges,,,,,,,,,,,,,,,406.58,,,fee schedule,,,406.58,,,fee schedule,,,398.45,,,fee schedule,,,,,,,,,889.56,,,percent of total billed charges,,,1036.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PRETREAT SERUM INCUB W DRUGS,3113727,CDM,302,RC,86975,CPT,5735,APC,,,,outpatient,facility,,,1139,1139,205.1,589.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,406.58,,,fee schedule,,,,,,,,,,,,,,,589.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",548.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,406.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,406.58,,,fee schedule,,,406.58,,,fee schedule,,,205.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AGGLUTININ COLD NS,3113735,CDM,302,RC,86156,CPT,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AGGLUTININ COLD NS,3113735,CDM,302,RC,86156,CPT,,,,,,outpatient,facility,,,25,10.5,6.75,24,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,8.07,,,fee schedule,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,8.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.5,,,percent of total billed charges,,,8.07,,,fee schedule,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,11.7,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.89,,,fee schedule,,,7.17,,,fee schedule,,,7.17,,,fee schedule,,,7.03,,,fee schedule,,,8.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,8.07,,,fee schedule,,,8.07,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB KAPPA LAMBDA LIGHT,3113750,CDM,301,RC,83883,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB KAPPA LAMBDA LIGHT,3113750,CDM,301,RC,83883,CPT,,,,,,outpatient,facility,,,69,28.98,11.84,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,13.6,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,13.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,13.6,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,19.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.36,,,fee schedule,,,12.08,,,fee schedule,,,12.08,,,fee schedule,,,11.84,,,fee schedule,,,13.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,13.6,,,fee schedule,,,13.6,,,fee schedule,,,13.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE BCR ABL1 BREAKPOINT MAJOR,3113784,CDM,310,RC,81206,CPT,,,,,,inpatient,facility,,,492,206.64,418.2,472.32,,418.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.04,,,percent of total billed charges,,,,,,,,,442.8,,,percent of total billed charges,,,472.32,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,457.56,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BCR ABL1 BREAKPOINT MAJOR,3113784,CDM,310,RC,81206,CPT,,,,,,outpatient,facility,,,492,206.64,132.84,492,,418.2,,,percent of total billed charges,,,132.84,,,percent of total billed charges,,,338.5,,,percent of total billed charges,,,331.12,,,percent of total billed charges,,,415.74,,,percent of total billed charges,,,163.96,,,fee schedule,,,428.04,,,percent of total billed charges,,,428.04,,,percent of total billed charges,,,418.2,,,percent of total billed charges,,,472.32,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,167.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",442.8,,,percent of total billed charges,,,163.96,,,fee schedule,,,457.56,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,237.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",221.35,,,fee schedule,,,492,,,fee schedule,,,492,,,fee schedule,,,492,,,fee schedule,,,163.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",384.25,,,percent of total billed charges,,,447.72,,,percent of total billed charges,,,163.96,,,fee schedule,,,163.96,,,fee schedule,,,143.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE BCR ABL1 BREAKPOINT MIN NS,3113792,CDM,310,RC,81207,CPT,,,,,,inpatient,facility,,,435,182.7,369.75,417.6,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.45,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,417.6,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,404.55,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BCR ABL1 BREAKPOINT MIN NS,3113792,CDM,310,RC,81207,CPT,,,,,,outpatient,facility,,,435,182.7,117.45,435,,369.75,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.75,,,percent of total billed charges,,,367.57,,,percent of total billed charges,,,144.84,,,fee schedule,,,378.45,,,percent of total billed charges,,,378.45,,,percent of total billed charges,,,369.75,,,percent of total billed charges,,,417.6,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,147.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",391.5,,,percent of total billed charges,,,144.84,,,fee schedule,,,404.55,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,210.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",195.53,,,fee schedule,,,435,,,fee schedule,,,435,,,fee schedule,,,435,,,fee schedule,,,144.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",339.74,,,percent of total billed charges,,,395.85,,,percent of total billed charges,,,144.84,,,fee schedule,,,144.84,,,fee schedule,,,,,,,,
LAB GENE BCR ABL1 BREAKPOINT OTHER,3113800,CDM,310,RC,81208,CPT,,,,,,inpatient,facility,,,644,270.48,547.4,618.24,,547.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,560.28,,,percent of total billed charges,,,,,,,,,579.6,,,percent of total billed charges,,,618.24,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,598.92,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BCR ABL1 BREAKPOINT OTHER,3113800,CDM,310,RC,81208,CPT,,,,,,outpatient,facility,,,644,270.48,173.88,644,,547.4,,,percent of total billed charges,,,173.88,,,percent of total billed charges,,,443.07,,,percent of total billed charges,,,433.41,,,percent of total billed charges,,,544.18,,,percent of total billed charges,,,214.62,,,fee schedule,,,560.28,,,percent of total billed charges,,,560.28,,,percent of total billed charges,,,547.4,,,percent of total billed charges,,,618.24,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,218.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",579.6,,,percent of total billed charges,,,214.62,,,fee schedule,,,598.92,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,311.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",289.74,,,fee schedule,,,644,,,fee schedule,,,644,,,fee schedule,,,644,,,fee schedule,,,214.62,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",502.96,,,percent of total billed charges,,,586.04,,,percent of total billed charges,,,214.62,,,fee schedule,,,214.62,,,fee schedule,,,,,,,,
LAB GENE BRAF VAR V600E NS,3113826,CDM,310,RC,81210,CPT,,,,,,inpatient,facility,,,527,221.34,447.95,505.92,,447.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.49,,,percent of total billed charges,,,,,,,,,474.3,,,percent of total billed charges,,,505.92,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,490.11,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BRAF VAR V600E NS,3113826,CDM,310,RC,81210,CPT,,,,,,outpatient,facility,,,527,221.34,142.29,527,,447.95,,,percent of total billed charges,,,142.29,,,percent of total billed charges,,,362.58,,,percent of total billed charges,,,354.67,,,percent of total billed charges,,,445.31,,,percent of total billed charges,,,175.4,,,fee schedule,,,458.49,,,percent of total billed charges,,,458.49,,,percent of total billed charges,,,447.95,,,percent of total billed charges,,,505.92,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,178.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",474.3,,,percent of total billed charges,,,175.4,,,fee schedule,,,490.11,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,254.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",236.79,,,fee schedule,,,527,,,fee schedule,,,527,,,fee schedule,,,527,,,fee schedule,,,175.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",411.59,,,percent of total billed charges,,,479.57,,,percent of total billed charges,,,175.4,,,fee schedule,,,175.4,,,fee schedule,,,,,,,,
LAB GENE CFTR VAR COMMON,3113909,CDM,310,RC,81220,CPT,,,,,,inpatient,facility,,,1670,701.4,1419.5,1603.2,,1419.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1452.9,,,percent of total billed charges,,,,,,,,,1503,,,percent of total billed charges,,,1603.2,,,percent of total billed charges,,,1586.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1553.1,,,percent of total billed charges,,,1586.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CFTR VAR COMMON,3113909,CDM,310,RC,81220,CPT,,,,,,outpatient,facility,,,1670,701.4,450.9,1603.2,,1419.5,,,percent of total billed charges,,,450.9,,,percent of total billed charges,,,1148.96,,,percent of total billed charges,,,1123.91,,,percent of total billed charges,,,1411.15,,,percent of total billed charges,,,556.6,,,fee schedule,,,1452.9,,,percent of total billed charges,,,1452.9,,,percent of total billed charges,,,1419.5,,,percent of total billed charges,,,1603.2,,,percent of total billed charges,,,1586.5,,,percent of total billed charges,,,567.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1503,,,percent of total billed charges,,,556.6,,,fee schedule,,,1553.1,,,percent of total billed charges,,,1586.5,,,percent of total billed charges,,,807.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",751.41,,,fee schedule,,,494.26,,,fee schedule,,,494.26,,,fee schedule,,,484.37,,,fee schedule,,,556.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1304.27,,,percent of total billed charges,,,1519.7,,,percent of total billed charges,,,556.6,,,fee schedule,,,556.6,,,fee schedule,,,487.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE CFTR VAR DUP DEL,3113925,CDM,310,RC,81222,CPT,,,,,,inpatient,facility,,,1306,548.52,1110.1,1253.76,,1110.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1136.22,,,percent of total billed charges,,,,,,,,,1175.4,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CFTR VAR DUP DEL,3113925,CDM,310,RC,81222,CPT,,,,,,outpatient,facility,,,1306,548.52,352.62,1253.76,,1110.1,,,percent of total billed charges,,,352.62,,,percent of total billed charges,,,898.53,,,percent of total billed charges,,,878.94,,,percent of total billed charges,,,1103.57,,,percent of total billed charges,,,435.07,,,fee schedule,,,1136.22,,,percent of total billed charges,,,1136.22,,,percent of total billed charges,,,1110.1,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,443.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1175.4,,,percent of total billed charges,,,435.07,,,fee schedule,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,630.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",587.34,,,fee schedule,,,386.34,,,fee schedule,,,386.34,,,fee schedule,,,378.61,,,fee schedule,,,435.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1019.99,,,percent of total billed charges,,,1188.46,,,percent of total billed charges,,,435.07,,,fee schedule,,,435.07,,,fee schedule,,,,,,,,
LAB GENE CFTR SEQ FULL,3113933,CDM,310,RC,81223,CPT,,,,,,inpatient,facility,,,1497,628.74,1272.45,1437.12,,1272.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1302.39,,,percent of total billed charges,,,,,,,,,1347.3,,,percent of total billed charges,,,1437.12,,,percent of total billed charges,,,1422.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1392.21,,,percent of total billed charges,,,1422.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CFTR SEQ FULL,3113933,CDM,310,RC,81223,CPT,,,,,,outpatient,facility,,,1497,628.74,404.19,1497,,1272.45,,,percent of total billed charges,,,404.19,,,percent of total billed charges,,,1029.94,,,percent of total billed charges,,,1007.48,,,percent of total billed charges,,,1264.96,,,percent of total billed charges,,,499,,,fee schedule,,,1302.39,,,percent of total billed charges,,,1302.39,,,percent of total billed charges,,,1272.45,,,percent of total billed charges,,,1437.12,,,percent of total billed charges,,,1422.15,,,percent of total billed charges,,,508.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1347.3,,,percent of total billed charges,,,499,,,fee schedule,,,1392.21,,,percent of total billed charges,,,1422.15,,,percent of total billed charges,,,723.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",673.65,,,fee schedule,,,1497,,,fee schedule,,,1497,,,fee schedule,,,1467.06,,,fee schedule,,,499,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1169.16,,,percent of total billed charges,,,1362.27,,,percent of total billed charges,,,499,,,fee schedule,,,499,,,fee schedule,,,,,,,,
LAB GENE CFTR INTRON 8 POLY T,3113941,CDM,310,RC,81224,CPT,,,,,,inpatient,facility,,,507,212.94,430.95,486.72,,430.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,441.09,,,percent of total billed charges,,,,,,,,,456.3,,,percent of total billed charges,,,486.72,,,percent of total billed charges,,,481.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,471.51,,,percent of total billed charges,,,481.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CFTR INTRON 8 POLY T,3113941,CDM,310,RC,81224,CPT,,,,,,outpatient,facility,,,507,212.94,136.89,486.72,,430.95,,,percent of total billed charges,,,136.89,,,percent of total billed charges,,,348.82,,,percent of total billed charges,,,341.21,,,percent of total billed charges,,,428.41,,,percent of total billed charges,,,168.75,,,fee schedule,,,441.09,,,percent of total billed charges,,,441.09,,,percent of total billed charges,,,430.95,,,percent of total billed charges,,,486.72,,,percent of total billed charges,,,481.65,,,percent of total billed charges,,,172.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",456.3,,,percent of total billed charges,,,168.75,,,fee schedule,,,471.51,,,percent of total billed charges,,,481.65,,,percent of total billed charges,,,244.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",227.81,,,fee schedule,,,149.85,,,fee schedule,,,149.85,,,fee schedule,,,146.85,,,fee schedule,,,168.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",395.97,,,percent of total billed charges,,,461.37,,,percent of total billed charges,,,168.75,,,fee schedule,,,168.75,,,fee schedule,,,,,,,,
LAB GENE CYP2C19 VAR COMMON NS,3113958,CDM,310,RC,81225,CPT,,,,,,inpatient,facility,,,875,367.5,743.75,840,,743.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,787.5,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CYP2C19 VAR COMMON NS,3113958,CDM,310,RC,81225,CPT,,,,,,outpatient,facility,,,875,367.5,236.25,875,,743.75,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,,602,,,percent of total billed charges,,,588.87,,,percent of total billed charges,,,739.38,,,percent of total billed charges,,,291.36,,,fee schedule,,,761.25,,,percent of total billed charges,,,761.25,,,percent of total billed charges,,,743.75,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,297.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",787.5,,,percent of total billed charges,,,291.36,,,fee schedule,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,422.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",393.34,,,fee schedule,,,875,,,fee schedule,,,875,,,fee schedule,,,875,,,fee schedule,,,291.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",683.38,,,percent of total billed charges,,,796.25,,,percent of total billed charges,,,291.36,,,fee schedule,,,291.36,,,fee schedule,,,,,,,,
LAB GENE F2 VAR 20210G MORE THANA NS,3114006,CDM,310,RC,81240,CPT,,,,,,inpatient,facility,,,198,83.16,168.3,190.08,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.26,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,190.08,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE F2 VAR 20210G MORE THANA NS,3114006,CDM,310,RC,81240,CPT,,,,,,outpatient,facility,,,198,83.16,53.46,190.08,,168.3,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,136.22,,,percent of total billed charges,,,133.25,,,percent of total billed charges,,,167.31,,,percent of total billed charges,,,65.69,,,fee schedule,,,172.26,,,percent of total billed charges,,,172.26,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,190.08,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",178.2,,,percent of total billed charges,,,65.69,,,fee schedule,,,184.14,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,95.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.68,,,fee schedule,,,58.33,,,fee schedule,,,58.33,,,fee schedule,,,57.16,,,fee schedule,,,65.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",154.64,,,percent of total billed charges,,,180.18,,,percent of total billed charges,,,65.69,,,fee schedule,,,65.69,,,fee schedule,,,57.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE F5 VAR LEIDEN,3114014,CDM,310,RC,81241,CPT,,,,,,inpatient,facility,,,221,92.82,187.85,212.16,,187.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.27,,,percent of total billed charges,,,,,,,,,198.9,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE F5 VAR LEIDEN,3114014,CDM,310,RC,81241,CPT,,,,,,outpatient,facility,,,221,92.82,59.67,212.16,,187.85,,,percent of total billed charges,,,59.67,,,percent of total billed charges,,,152.05,,,percent of total billed charges,,,148.73,,,percent of total billed charges,,,186.75,,,percent of total billed charges,,,73.37,,,fee schedule,,,192.27,,,percent of total billed charges,,,192.27,,,percent of total billed charges,,,187.85,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,74.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",198.9,,,percent of total billed charges,,,73.37,,,fee schedule,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,106.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",99.05,,,fee schedule,,,65.15,,,fee schedule,,,65.15,,,fee schedule,,,63.85,,,fee schedule,,,73.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",172.6,,,percent of total billed charges,,,201.11,,,percent of total billed charges,,,73.37,,,fee schedule,,,73.37,,,fee schedule,,,64.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE FMR1 DET ALLELES ABNORMAL,3114030,CDM,310,RC,81243,CPT,,,,,,inpatient,facility,,,172,72.24,146.2,165.12,,146.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,149.64,,,percent of total billed charges,,,,,,,,,154.8,,,percent of total billed charges,,,165.12,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,159.96,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE FMR1 DET ALLELES ABNORMAL,3114030,CDM,310,RC,81243,CPT,,,,,,outpatient,facility,,,172,72.24,46.44,172,,146.2,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,118.34,,,percent of total billed charges,,,115.76,,,percent of total billed charges,,,145.34,,,percent of total billed charges,,,57.04,,,fee schedule,,,149.64,,,percent of total billed charges,,,149.64,,,percent of total billed charges,,,146.2,,,percent of total billed charges,,,165.12,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,58.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",154.8,,,percent of total billed charges,,,57.04,,,fee schedule,,,159.96,,,percent of total billed charges,,,163.4,,,percent of total billed charges,,,82.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",77,,,fee schedule,,,172,,,fee schedule,,,172,,,fee schedule,,,172,,,fee schedule,,,57.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",134.33,,,percent of total billed charges,,,156.52,,,percent of total billed charges,,,57.04,,,fee schedule,,,57.04,,,fee schedule,,,,,,,,
LAB GENE FLT3 VAR ITD,3114055,CDM,310,RC,81245,CPT,,,,,,inpatient,facility,,,497,208.74,422.45,477.12,,422.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,432.39,,,percent of total billed charges,,,,,,,,,447.3,,,percent of total billed charges,,,477.12,,,percent of total billed charges,,,472.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,462.21,,,percent of total billed charges,,,472.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE FLT3 VAR ITD,3114055,CDM,310,RC,81245,CPT,,,,,,outpatient,facility,,,497,208.74,134.19,497,,422.45,,,percent of total billed charges,,,134.19,,,percent of total billed charges,,,341.94,,,percent of total billed charges,,,334.48,,,percent of total billed charges,,,419.96,,,percent of total billed charges,,,165.51,,,fee schedule,,,432.39,,,percent of total billed charges,,,432.39,,,percent of total billed charges,,,422.45,,,percent of total billed charges,,,477.12,,,percent of total billed charges,,,472.15,,,percent of total billed charges,,,168.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",447.3,,,percent of total billed charges,,,165.51,,,fee schedule,,,462.21,,,percent of total billed charges,,,472.15,,,percent of total billed charges,,,239.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",223.44,,,fee schedule,,,497,,,fee schedule,,,497,,,fee schedule,,,497,,,fee schedule,,,165.51,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",388.16,,,percent of total billed charges,,,452.27,,,percent of total billed charges,,,165.51,,,fee schedule,,,165.51,,,fee schedule,,,,,,,,
LAB GENE HFE VAR COMMON NS,3114097,CDM,310,RC,81256,CPT,,,,,,inpatient,facility,,,197,82.74,167.45,189.12,,167.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.39,,,percent of total billed charges,,,,,,,,,177.3,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE HFE VAR COMMON NS,3114097,CDM,310,RC,81256,CPT,,,,,,outpatient,facility,,,197,82.74,53.19,197,,167.45,,,percent of total billed charges,,,53.19,,,percent of total billed charges,,,135.54,,,percent of total billed charges,,,132.58,,,percent of total billed charges,,,166.47,,,percent of total billed charges,,,65.36,,,fee schedule,,,171.39,,,percent of total billed charges,,,171.39,,,percent of total billed charges,,,167.45,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,66.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",177.3,,,percent of total billed charges,,,65.36,,,fee schedule,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,94.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.24,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,65.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",153.86,,,percent of total billed charges,,,179.27,,,percent of total billed charges,,,65.36,,,fee schedule,,,65.36,,,fee schedule,,,,,,,,
LAB GENE HBA1 HBA2 DEL VAR COMMON,3114105,CDM,310,RC,81257,CPT,,,,,,inpatient,facility,,,830,348.6,705.5,796.8,,705.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,722.1,,,percent of total billed charges,,,,,,,,,747,,,percent of total billed charges,,,796.8,,,percent of total billed charges,,,788.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,771.9,,,percent of total billed charges,,,788.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE HBA1 HBA2 DEL VAR COMMON,3114105,CDM,310,RC,81257,CPT,,,,,,outpatient,facility,,,830,348.6,102.26,830,,705.5,,,percent of total billed charges,,,224.1,,,percent of total billed charges,,,571.04,,,percent of total billed charges,,,558.59,,,percent of total billed charges,,,701.35,,,percent of total billed charges,,,102.26,,,fee schedule,,,722.1,,,percent of total billed charges,,,722.1,,,percent of total billed charges,,,705.5,,,percent of total billed charges,,,796.8,,,percent of total billed charges,,,788.5,,,percent of total billed charges,,,104.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",747,,,percent of total billed charges,,,102.26,,,fee schedule,,,771.9,,,percent of total billed charges,,,788.5,,,percent of total billed charges,,,148.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",138.05,,,fee schedule,,,830,,,fee schedule,,,830,,,fee schedule,,,830,,,fee schedule,,,102.26,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",648.23,,,percent of total billed charges,,,755.3,,,percent of total billed charges,,,102.26,,,fee schedule,,,102.26,,,fee schedule,,,,,,,,
LAB GENE IGH REARRANGEMENT AMP,3114121,CDM,310,RC,81261,CPT,,,,,,inpatient,facility,,,594,249.48,504.9,570.24,,504.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,516.78,,,percent of total billed charges,,,,,,,,,534.6,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE IGH REARRANGEMENT AMP,3114121,CDM,310,RC,81261,CPT,,,,,,outpatient,facility,,,594,249.48,160.38,594,,504.9,,,percent of total billed charges,,,160.38,,,percent of total billed charges,,,408.67,,,percent of total billed charges,,,399.76,,,percent of total billed charges,,,501.93,,,percent of total billed charges,,,197.99,,,fee schedule,,,516.78,,,percent of total billed charges,,,516.78,,,percent of total billed charges,,,504.9,,,percent of total billed charges,,,570.24,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,201.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",534.6,,,percent of total billed charges,,,197.99,,,fee schedule,,,552.42,,,percent of total billed charges,,,564.3,,,percent of total billed charges,,,287.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",267.29,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,594,,,fee schedule,,,197.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",463.91,,,percent of total billed charges,,,540.54,,,percent of total billed charges,,,197.99,,,fee schedule,,,197.99,,,fee schedule,,,,,,,,
LAB GENE IGH MUT VARIABLE REGION,3114147,CDM,310,RC,81263,CPT,,,,,,inpatient,facility,,,884,371.28,751.4,848.64,,751.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,769.08,,,percent of total billed charges,,,,,,,,,795.6,,,percent of total billed charges,,,848.64,,,percent of total billed charges,,,839.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,822.12,,,percent of total billed charges,,,839.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE IGH MUT VARIABLE REGION,3114147,CDM,310,RC,81263,CPT,,,,,,outpatient,facility,,,884,371.28,238.68,884,,751.4,,,percent of total billed charges,,,238.68,,,percent of total billed charges,,,608.19,,,percent of total billed charges,,,594.93,,,percent of total billed charges,,,746.98,,,percent of total billed charges,,,294.52,,,fee schedule,,,769.08,,,percent of total billed charges,,,769.08,,,percent of total billed charges,,,751.4,,,percent of total billed charges,,,848.64,,,percent of total billed charges,,,839.8,,,percent of total billed charges,,,300.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",795.6,,,percent of total billed charges,,,294.52,,,fee schedule,,,822.12,,,percent of total billed charges,,,839.8,,,percent of total billed charges,,,427.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",397.6,,,fee schedule,,,884,,,fee schedule,,,884,,,fee schedule,,,884,,,fee schedule,,,294.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",690.4,,,percent of total billed charges,,,804.44,,,percent of total billed charges,,,294.52,,,fee schedule,,,294.52,,,fee schedule,,,,,,,,
LAB GENE IGK REARRANGEMENT CLONAL,3114154,CDM,310,RC,81264,CPT,,,,,,inpatient,facility,,,540,226.8,459,518.4,,459,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,469.8,,,percent of total billed charges,,,,,,,,,486,,,percent of total billed charges,,,518.4,,,percent of total billed charges,,,513,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,502.2,,,percent of total billed charges,,,513,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE IGK REARRANGEMENT CLONAL,3114154,CDM,310,RC,81264,CPT,,,,,,outpatient,facility,,,540,226.8,145.8,540,,459,,,percent of total billed charges,,,145.8,,,percent of total billed charges,,,371.52,,,percent of total billed charges,,,363.42,,,percent of total billed charges,,,456.3,,,percent of total billed charges,,,172.73,,,fee schedule,,,469.8,,,percent of total billed charges,,,469.8,,,percent of total billed charges,,,459,,,percent of total billed charges,,,518.4,,,percent of total billed charges,,,513,,,percent of total billed charges,,,176.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",486,,,percent of total billed charges,,,172.73,,,fee schedule,,,502.2,,,percent of total billed charges,,,513,,,percent of total billed charges,,,250.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",233.19,,,fee schedule,,,540,,,fee schedule,,,540,,,fee schedule,,,540,,,fee schedule,,,172.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",421.74,,,percent of total billed charges,,,491.4,,,percent of total billed charges,,,172.73,,,fee schedule,,,172.73,,,fee schedule,,,,,,,,
LAB GENE MARKERS STR SPEC PT ANDCOMP,3114162,CDM,310,RC,81265,CPT,,,,,,inpatient,facility,,,700,294,595,672,,595,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,609,,,percent of total billed charges,,,,,,,,,630,,,percent of total billed charges,,,672,,,percent of total billed charges,,,665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,651,,,percent of total billed charges,,,665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MARKERS STR SPEC PT ANDCOMP,3114162,CDM,310,RC,81265,CPT,,,,,,outpatient,facility,,,700,294,189,700,,595,,,percent of total billed charges,,,189,,,percent of total billed charges,,,481.6,,,percent of total billed charges,,,471.1,,,percent of total billed charges,,,591.5,,,percent of total billed charges,,,233.07,,,fee schedule,,,609,,,percent of total billed charges,,,609,,,percent of total billed charges,,,595,,,percent of total billed charges,,,672,,,percent of total billed charges,,,665,,,percent of total billed charges,,,237.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",630,,,percent of total billed charges,,,233.07,,,fee schedule,,,651,,,percent of total billed charges,,,665,,,percent of total billed charges,,,337.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",314.64,,,fee schedule,,,700,,,fee schedule,,,700,,,fee schedule,,,700,,,fee schedule,,,233.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",546.7,,,percent of total billed charges,,,637,,,percent of total billed charges,,,233.07,,,fee schedule,,,233.07,,,fee schedule,,,,,,,,
LAB GENE CHIMERISM WO CELL SLCT,3114188,CDM,310,RC,81267,CPT,,,,,,inpatient,facility,,,623,261.66,529.55,598.08,,529.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,542.01,,,percent of total billed charges,,,,,,,,,560.7,,,percent of total billed charges,,,598.08,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,579.39,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CHIMERISM WO CELL SLCT,3114188,CDM,310,RC,81267,CPT,,,,,,outpatient,facility,,,623,261.66,168.21,623,,529.55,,,percent of total billed charges,,,168.21,,,percent of total billed charges,,,428.62,,,percent of total billed charges,,,419.28,,,percent of total billed charges,,,526.43,,,percent of total billed charges,,,207.46,,,fee schedule,,,542.01,,,percent of total billed charges,,,542.01,,,percent of total billed charges,,,529.55,,,percent of total billed charges,,,598.08,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,211.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",560.7,,,percent of total billed charges,,,207.46,,,fee schedule,,,579.39,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,300.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",280.07,,,fee schedule,,,623,,,fee schedule,,,623,,,fee schedule,,,623,,,fee schedule,,,207.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",486.56,,,percent of total billed charges,,,566.93,,,percent of total billed charges,,,207.46,,,fee schedule,,,207.46,,,fee schedule,,,,,,,,
LAB GENE CHIMERISM W CELL SLCT EA,3114196,CDM,310,RC,81268,CPT,,,,,,inpatient,facility,,,783,328.86,665.55,751.68,,665.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,681.21,,,percent of total billed charges,,,,,,,,,704.7,,,percent of total billed charges,,,751.68,,,percent of total billed charges,,,743.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,728.19,,,percent of total billed charges,,,743.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CHIMERISM W CELL SLCT EA,3114196,CDM,310,RC,81268,CPT,,,,,,outpatient,facility,,,783,328.86,211.41,783,,665.55,,,percent of total billed charges,,,211.41,,,percent of total billed charges,,,538.7,,,percent of total billed charges,,,526.96,,,percent of total billed charges,,,661.63,,,percent of total billed charges,,,260.79,,,fee schedule,,,681.21,,,percent of total billed charges,,,681.21,,,percent of total billed charges,,,665.55,,,percent of total billed charges,,,751.68,,,percent of total billed charges,,,743.85,,,percent of total billed charges,,,266.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",704.7,,,percent of total billed charges,,,260.79,,,fee schedule,,,728.19,,,percent of total billed charges,,,743.85,,,percent of total billed charges,,,378.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",352.07,,,fee schedule,,,783,,,fee schedule,,,783,,,fee schedule,,,783,,,fee schedule,,,260.79,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",611.52,,,percent of total billed charges,,,712.53,,,percent of total billed charges,,,260.79,,,fee schedule,,,260.79,,,fee schedule,,,,,,,,
LAB GENE JAK2 VAR V617F NS,3114204,CDM,310,RC,81270,CPT,,,,,,inpatient,facility,,,275,115.5,233.75,264,,233.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.25,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE JAK2 VAR V617F NS,3114204,CDM,310,RC,81270,CPT,,,,,,outpatient,facility,,,275,115.5,74.25,275,,233.75,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,189.2,,,percent of total billed charges,,,185.07,,,percent of total billed charges,,,232.38,,,percent of total billed charges,,,91.66,,,fee schedule,,,239.25,,,percent of total billed charges,,,239.25,,,percent of total billed charges,,,233.75,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,93.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",247.5,,,percent of total billed charges,,,91.66,,,fee schedule,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,132.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",123.74,,,fee schedule,,,275,,,fee schedule,,,275,,,fee schedule,,,275,,,fee schedule,,,91.66,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",214.78,,,percent of total billed charges,,,250.25,,,percent of total billed charges,,,91.66,,,fee schedule,,,91.66,,,fee schedule,,,,,,,,
LAB GENE KRAS VAR CODONS 12 AND13 NS,3114212,CDM,310,RC,81275,CPT,,,,,,inpatient,facility,,,580,243.6,493,556.8,,493,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,504.6,,,percent of total billed charges,,,,,,,,,522,,,percent of total billed charges,,,556.8,,,percent of total billed charges,,,551,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,539.4,,,percent of total billed charges,,,551,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE KRAS VAR CODONS 12 AND13 NS,3114212,CDM,310,RC,81275,CPT,,,,,,outpatient,facility,,,580,243.6,156.6,556.8,,493,,,percent of total billed charges,,,156.6,,,percent of total billed charges,,,399.04,,,percent of total billed charges,,,390.34,,,percent of total billed charges,,,490.1,,,percent of total billed charges,,,193.25,,,fee schedule,,,504.6,,,percent of total billed charges,,,504.6,,,percent of total billed charges,,,493,,,percent of total billed charges,,,556.8,,,percent of total billed charges,,,551,,,percent of total billed charges,,,197.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",522,,,percent of total billed charges,,,193.25,,,fee schedule,,,539.4,,,percent of total billed charges,,,551,,,percent of total billed charges,,,280.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",260.89,,,fee schedule,,,171.61,,,fee schedule,,,171.61,,,fee schedule,,,168.18,,,fee schedule,,,193.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",452.98,,,percent of total billed charges,,,527.8,,,percent of total billed charges,,,193.25,,,fee schedule,,,193.25,,,fee schedule,,,,,,,,
LAB GENE MTHFR VAR COMMON NS,3114261,CDM,310,RC,81291,CPT,,,,,,inpatient,facility,,,197,82.74,167.45,189.12,,167.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.39,,,percent of total billed charges,,,,,,,,,177.3,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MTHFR VAR COMMON NS,3114261,CDM,310,RC,81291,CPT,,,,,,outpatient,facility,,,197,82.74,53.19,197,,167.45,,,percent of total billed charges,,,53.19,,,percent of total billed charges,,,135.54,,,percent of total billed charges,,,132.58,,,percent of total billed charges,,,166.47,,,percent of total billed charges,,,65.34,,,fee schedule,,,171.39,,,percent of total billed charges,,,171.39,,,percent of total billed charges,,,167.45,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,66.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",177.3,,,percent of total billed charges,,,65.34,,,fee schedule,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,94.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.21,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,65.34,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",153.86,,,percent of total billed charges,,,179.27,,,percent of total billed charges,,,65.34,,,fee schedule,,,65.34,,,fee schedule,,,57.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE INSTABILITY MICROSATELLITE,3114360,CDM,310,RC,81301,CPT,,,,,,inpatient,facility,,,1046,439.32,889.1,1004.16,,889.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.02,,,percent of total billed charges,,,,,,,,,941.4,,,percent of total billed charges,,,1004.16,,,percent of total billed charges,,,993.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,972.78,,,percent of total billed charges,,,993.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE INSTABILITY MICROSATELLITE,3114360,CDM,310,RC,81301,CPT,,,,,,outpatient,facility,,,1046,439.32,282.42,1046,,889.1,,,percent of total billed charges,,,282.42,,,percent of total billed charges,,,719.65,,,percent of total billed charges,,,703.96,,,percent of total billed charges,,,883.87,,,percent of total billed charges,,,348.56,,,fee schedule,,,910.02,,,percent of total billed charges,,,910.02,,,percent of total billed charges,,,889.1,,,percent of total billed charges,,,1004.16,,,percent of total billed charges,,,993.7,,,percent of total billed charges,,,355.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.4,,,percent of total billed charges,,,348.56,,,fee schedule,,,972.78,,,percent of total billed charges,,,993.7,,,percent of total billed charges,,,505.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",470.56,,,fee schedule,,,1046,,,fee schedule,,,1046,,,fee schedule,,,1046,,,fee schedule,,,348.56,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",816.93,,,percent of total billed charges,,,951.86,,,percent of total billed charges,,,348.56,,,fee schedule,,,348.56,,,fee schedule,,,,,,,,
LAB GENE NPM1 VAR EXON 12,3114402,CDM,310,RC,81310,CPT,,,,,,inpatient,facility,,,740,310.8,629,710.4,,629,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,643.8,,,percent of total billed charges,,,,,,,,,666,,,percent of total billed charges,,,710.4,,,percent of total billed charges,,,703,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,688.2,,,percent of total billed charges,,,703,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE NPM1 VAR EXON 12,3114402,CDM,310,RC,81310,CPT,,,,,,outpatient,facility,,,740,310.8,199.8,740,,629,,,percent of total billed charges,,,199.8,,,percent of total billed charges,,,509.12,,,percent of total billed charges,,,498.02,,,percent of total billed charges,,,625.3,,,percent of total billed charges,,,246.52,,,fee schedule,,,643.8,,,percent of total billed charges,,,643.8,,,percent of total billed charges,,,629,,,percent of total billed charges,,,710.4,,,percent of total billed charges,,,703,,,percent of total billed charges,,,251.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",666,,,percent of total billed charges,,,246.52,,,fee schedule,,,688.2,,,percent of total billed charges,,,703,,,percent of total billed charges,,,357.45,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",332.8,,,fee schedule,,,740,,,fee schedule,,,740,,,fee schedule,,,740,,,fee schedule,,,246.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",577.94,,,percent of total billed charges,,,673.4,,,percent of total billed charges,,,246.52,,,fee schedule,,,246.52,,,fee schedule,,,,,,,,
LAB GENE PML RARALPHA BREAKPOINTS,3114410,CDM,310,RC,81315,CPT,,,,,,inpatient,facility,,,622,261.24,528.7,597.12,,528.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.14,,,percent of total billed charges,,,,,,,,,559.8,,,percent of total billed charges,,,597.12,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.46,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE PML RARALPHA BREAKPOINTS,3114410,CDM,310,RC,81315,CPT,,,,,,outpatient,facility,,,622,261.24,167.94,622,,528.7,,,percent of total billed charges,,,167.94,,,percent of total billed charges,,,427.94,,,percent of total billed charges,,,418.61,,,percent of total billed charges,,,525.59,,,percent of total billed charges,,,207.31,,,fee schedule,,,541.14,,,percent of total billed charges,,,541.14,,,percent of total billed charges,,,528.7,,,percent of total billed charges,,,597.12,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,211.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",559.8,,,percent of total billed charges,,,207.31,,,fee schedule,,,578.46,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,300.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",279.87,,,fee schedule,,,622,,,fee schedule,,,622,,,fee schedule,,,622,,,fee schedule,,,207.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",485.78,,,percent of total billed charges,,,566.02,,,percent of total billed charges,,,207.31,,,fee schedule,,,207.31,,,fee schedule,,,,,,,,
LAB GENE SNRPN UBE3A METHYLATION,3114477,CDM,310,RC,81331,CPT,,,,,,inpatient,facility,,,292,122.64,248.2,280.32,,248.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.04,,,percent of total billed charges,,,,,,,,,262.8,,,percent of total billed charges,,,280.32,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,271.56,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE SNRPN UBE3A METHYLATION,3114477,CDM,310,RC,81331,CPT,,,,,,outpatient,facility,,,292,122.64,51.07,292,,248.2,,,percent of total billed charges,,,78.84,,,percent of total billed charges,,,200.9,,,percent of total billed charges,,,196.52,,,percent of total billed charges,,,246.74,,,percent of total billed charges,,,51.07,,,fee schedule,,,254.04,,,percent of total billed charges,,,254.04,,,percent of total billed charges,,,248.2,,,percent of total billed charges,,,280.32,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,52.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",262.8,,,percent of total billed charges,,,51.07,,,fee schedule,,,271.56,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,74.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.94,,,fee schedule,,,292,,,fee schedule,,,292,,,fee schedule,,,292,,,fee schedule,,,51.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",228.05,,,percent of total billed charges,,,265.72,,,percent of total billed charges,,,51.07,,,fee schedule,,,51.07,,,fee schedule,,,,,,,,
LAB GENE TRB REARRANGEMENT AMP,3114493,CDM,310,RC,81340,CPT,,,,,,inpatient,facility,,,627,263.34,532.95,601.92,,532.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,545.49,,,percent of total billed charges,,,,,,,,,564.3,,,percent of total billed charges,,,601.92,,,percent of total billed charges,,,595.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,583.11,,,percent of total billed charges,,,595.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TRB REARRANGEMENT AMP,3114493,CDM,310,RC,81340,CPT,,,,,,outpatient,facility,,,627,263.34,169.29,627,,532.95,,,percent of total billed charges,,,169.29,,,percent of total billed charges,,,431.38,,,percent of total billed charges,,,421.97,,,percent of total billed charges,,,529.81,,,percent of total billed charges,,,208.92,,,fee schedule,,,545.49,,,percent of total billed charges,,,545.49,,,percent of total billed charges,,,532.95,,,percent of total billed charges,,,601.92,,,percent of total billed charges,,,595.65,,,percent of total billed charges,,,213.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",564.3,,,percent of total billed charges,,,208.92,,,fee schedule,,,583.11,,,percent of total billed charges,,,595.65,,,percent of total billed charges,,,302.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",282.04,,,fee schedule,,,627,,,fee schedule,,,627,,,fee schedule,,,627,,,fee schedule,,,208.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",489.69,,,percent of total billed charges,,,570.57,,,percent of total billed charges,,,208.92,,,fee schedule,,,208.92,,,fee schedule,,,,,,,,
LAB GENE TRG REARRANGEMENT CLONAL,3114519,CDM,310,RC,81342,CPT,,,,,,inpatient,facility,,,605,254.1,514.25,580.8,,514.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,526.35,,,percent of total billed charges,,,,,,,,,544.5,,,percent of total billed charges,,,580.8,,,percent of total billed charges,,,574.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,562.65,,,percent of total billed charges,,,574.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TRG REARRANGEMENT CLONAL,3114519,CDM,310,RC,81342,CPT,,,,,,outpatient,facility,,,605,254.1,163.35,605,,514.25,,,percent of total billed charges,,,163.35,,,percent of total billed charges,,,416.24,,,percent of total billed charges,,,407.16,,,percent of total billed charges,,,511.22,,,percent of total billed charges,,,201.5,,,fee schedule,,,526.35,,,percent of total billed charges,,,526.35,,,percent of total billed charges,,,514.25,,,percent of total billed charges,,,580.8,,,percent of total billed charges,,,574.75,,,percent of total billed charges,,,205.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",544.5,,,percent of total billed charges,,,201.5,,,fee schedule,,,562.65,,,percent of total billed charges,,,574.75,,,percent of total billed charges,,,292.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",272.03,,,fee schedule,,,605,,,fee schedule,,,605,,,fee schedule,,,605,,,fee schedule,,,201.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",472.5,,,percent of total billed charges,,,550.55,,,percent of total billed charges,,,201.5,,,fee schedule,,,201.5,,,fee schedule,,,,,,,,
LAB GENE UGT1A1 VAR COMMON NS,3114527,CDM,310,RC,81350,CPT,,,,,,inpatient,facility,,,702,294.84,596.7,673.92,,596.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,610.74,,,percent of total billed charges,,,,,,,,,631.8,,,percent of total billed charges,,,673.92,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,652.86,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE UGT1A1 VAR COMMON NS,3114527,CDM,310,RC,81350,CPT,,,,,,outpatient,facility,,,702,294.84,189.54,702,,596.7,,,percent of total billed charges,,,189.54,,,percent of total billed charges,,,482.98,,,percent of total billed charges,,,472.45,,,percent of total billed charges,,,593.19,,,percent of total billed charges,,,234,,,fee schedule,,,610.74,,,percent of total billed charges,,,610.74,,,percent of total billed charges,,,596.7,,,percent of total billed charges,,,673.92,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,238.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",631.8,,,percent of total billed charges,,,234,,,fee schedule,,,652.86,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,339.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",315.9,,,fee schedule,,,702,,,fee schedule,,,702,,,fee schedule,,,702,,,fee schedule,,,234,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",548.26,,,percent of total billed charges,,,638.82,,,percent of total billed charges,,,234,,,fee schedule,,,234,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 1 AND2 LR,3114543,CDM,310,RC,81370,CPT,,,,,,inpatient,facility,,,1207,506.94,1025.95,1158.72,,1025.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1050.09,,,percent of total billed charges,,,,,,,,,1086.3,,,percent of total billed charges,,,1158.72,,,percent of total billed charges,,,1146.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1122.51,,,percent of total billed charges,,,1146.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 AND2 LR,3114543,CDM,310,RC,81370,CPT,,,,,,outpatient,facility,,,1207,506.94,325.89,1158.72,,1025.95,,,percent of total billed charges,,,325.89,,,percent of total billed charges,,,830.42,,,percent of total billed charges,,,812.31,,,percent of total billed charges,,,1019.91,,,percent of total billed charges,,,402.12,,,fee schedule,,,1050.09,,,percent of total billed charges,,,1050.09,,,percent of total billed charges,,,1025.95,,,percent of total billed charges,,,1158.72,,,percent of total billed charges,,,1146.65,,,percent of total billed charges,,,410.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1086.3,,,percent of total billed charges,,,402.12,,,fee schedule,,,1122.51,,,percent of total billed charges,,,1146.65,,,percent of total billed charges,,,583.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",542.86,,,fee schedule,,,357.08,,,fee schedule,,,357.08,,,fee schedule,,,349.94,,,fee schedule,,,402.12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",942.67,,,percent of total billed charges,,,1098.37,,,percent of total billed charges,,,402.12,,,fee schedule,,,402.12,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 1 LR CMP,3114568,CDM,310,RC,81372,CPT,,,,,,inpatient,facility,,,1211,508.62,1029.35,1162.56,,1029.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1053.57,,,percent of total billed charges,,,,,,,,,1089.9,,,percent of total billed charges,,,1162.56,,,percent of total billed charges,,,1150.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1126.23,,,percent of total billed charges,,,1150.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 LR CMP,3114568,CDM,310,RC,81372,CPT,,,,,,outpatient,facility,,,1211,508.62,326.97,1162.56,,1029.35,,,percent of total billed charges,,,326.97,,,percent of total billed charges,,,833.17,,,percent of total billed charges,,,815,,,percent of total billed charges,,,1023.29,,,percent of total billed charges,,,403.59,,,fee schedule,,,1053.57,,,percent of total billed charges,,,1053.57,,,percent of total billed charges,,,1029.35,,,percent of total billed charges,,,1162.56,,,percent of total billed charges,,,1150.45,,,percent of total billed charges,,,411.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1089.9,,,percent of total billed charges,,,403.59,,,fee schedule,,,1126.23,,,percent of total billed charges,,,1150.45,,,percent of total billed charges,,,585.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",544.85,,,fee schedule,,,358.39,,,fee schedule,,,358.39,,,fee schedule,,,351.22,,,fee schedule,,,403.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",945.79,,,percent of total billed charges,,,1102.01,,,percent of total billed charges,,,403.59,,,fee schedule,,,403.59,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 1 LR AG 1 EA,3114584,CDM,310,RC,81374,CPT,,,,,,inpatient,facility,,,223,93.66,189.55,214.08,,189.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,194.01,,,percent of total billed charges,,,,,,,,,200.7,,,percent of total billed charges,,,214.08,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,207.39,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 LR AG 1 EA,3114584,CDM,310,RC,81374,CPT,,,,,,outpatient,facility,,,223,93.66,60.21,214.08,,189.55,,,percent of total billed charges,,,60.21,,,percent of total billed charges,,,153.42,,,percent of total billed charges,,,150.08,,,percent of total billed charges,,,188.44,,,percent of total billed charges,,,74.33,,,fee schedule,,,194.01,,,percent of total billed charges,,,194.01,,,percent of total billed charges,,,189.55,,,percent of total billed charges,,,214.08,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,75.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",200.7,,,percent of total billed charges,,,74.33,,,fee schedule,,,207.39,,,percent of total billed charges,,,211.85,,,percent of total billed charges,,,107.78,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.35,,,fee schedule,,,66.01,,,fee schedule,,,66.01,,,fee schedule,,,64.69,,,fee schedule,,,74.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",174.16,,,percent of total billed charges,,,202.93,,,percent of total billed charges,,,74.33,,,fee schedule,,,74.33,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 2 LR AG 1 EA,3114618,CDM,310,RC,81377,CPT,,,,,,inpatient,facility,,,285,119.7,242.25,273.6,,242.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,247.95,,,percent of total billed charges,,,,,,,,,256.5,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,265.05,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 2 LR AG 1 EA,3114618,CDM,310,RC,81377,CPT,,,,,,outpatient,facility,,,285,119.7,76.95,273.6,,242.25,,,percent of total billed charges,,,76.95,,,percent of total billed charges,,,196.08,,,percent of total billed charges,,,191.8,,,percent of total billed charges,,,240.82,,,percent of total billed charges,,,94.74,,,fee schedule,,,247.95,,,percent of total billed charges,,,247.95,,,percent of total billed charges,,,242.25,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,96.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",256.5,,,percent of total billed charges,,,94.74,,,fee schedule,,,265.05,,,percent of total billed charges,,,270.75,,,percent of total billed charges,,,137.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",127.9,,,fee schedule,,,84.13,,,fee schedule,,,84.13,,,fee schedule,,,82.45,,,fee schedule,,,94.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",222.59,,,percent of total billed charges,,,259.35,,,percent of total billed charges,,,94.74,,,fee schedule,,,94.74,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 1 HR CMP,3114634,CDM,310,RC,81379,CPT,,,,,,inpatient,facility,,,1007,422.94,855.95,966.72,,855.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,876.09,,,percent of total billed charges,,,,,,,,,906.3,,,percent of total billed charges,,,966.72,,,percent of total billed charges,,,956.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,936.51,,,percent of total billed charges,,,956.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 HR CMP,3114634,CDM,310,RC,81379,CPT,,,,,,outpatient,facility,,,1007,422.94,271.89,966.72,,855.95,,,percent of total billed charges,,,271.89,,,percent of total billed charges,,,692.82,,,percent of total billed charges,,,677.71,,,percent of total billed charges,,,850.91,,,percent of total billed charges,,,335.38,,,fee schedule,,,876.09,,,percent of total billed charges,,,876.09,,,percent of total billed charges,,,855.95,,,percent of total billed charges,,,966.72,,,percent of total billed charges,,,956.65,,,percent of total billed charges,,,342.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",906.3,,,percent of total billed charges,,,335.38,,,fee schedule,,,936.51,,,percent of total billed charges,,,956.65,,,percent of total billed charges,,,486.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",452.76,,,fee schedule,,,297.82,,,fee schedule,,,297.82,,,fee schedule,,,291.86,,,fee schedule,,,335.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",786.47,,,percent of total billed charges,,,916.37,,,percent of total billed charges,,,335.38,,,fee schedule,,,335.38,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 1 HR LOCUS EA,3114642,CDM,310,RC,81380,CPT,,,,,,inpatient,facility,,,532,223.44,452.2,510.72,,452.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.84,,,percent of total billed charges,,,,,,,,,478.8,,,percent of total billed charges,,,510.72,,,percent of total billed charges,,,505.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,494.76,,,percent of total billed charges,,,505.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 HR LOCUS EA,3114642,CDM,310,RC,81380,CPT,,,,,,outpatient,facility,,,532,223.44,143.64,510.72,,452.2,,,percent of total billed charges,,,143.64,,,percent of total billed charges,,,366.02,,,percent of total billed charges,,,358.04,,,percent of total billed charges,,,449.54,,,percent of total billed charges,,,177.25,,,fee schedule,,,462.84,,,percent of total billed charges,,,462.84,,,percent of total billed charges,,,452.2,,,percent of total billed charges,,,510.72,,,percent of total billed charges,,,505.4,,,percent of total billed charges,,,180.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",478.8,,,percent of total billed charges,,,177.25,,,fee schedule,,,494.76,,,percent of total billed charges,,,505.4,,,percent of total billed charges,,,257.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",239.29,,,fee schedule,,,157.4,,,fee schedule,,,157.4,,,fee schedule,,,154.25,,,fee schedule,,,177.25,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",415.49,,,percent of total billed charges,,,484.12,,,percent of total billed charges,,,177.25,,,fee schedule,,,177.25,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 1 HR ALLE 1 GRP,3114659,CDM,310,RC,81381,CPT,,,,,,inpatient,facility,,,510,214.2,433.5,489.6,,433.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,443.7,,,percent of total billed charges,,,,,,,,,459,,,percent of total billed charges,,,489.6,,,percent of total billed charges,,,484.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,474.3,,,percent of total billed charges,,,484.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 HR ALLE 1 GRP,3114659,CDM,310,RC,81381,CPT,,,,,,outpatient,facility,,,510,214.2,137.7,489.6,,433.5,,,percent of total billed charges,,,137.7,,,percent of total billed charges,,,350.88,,,percent of total billed charges,,,343.23,,,percent of total billed charges,,,430.95,,,percent of total billed charges,,,169.9,,,fee schedule,,,443.7,,,percent of total billed charges,,,443.7,,,percent of total billed charges,,,433.5,,,percent of total billed charges,,,489.6,,,percent of total billed charges,,,484.5,,,percent of total billed charges,,,173.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",459,,,percent of total billed charges,,,169.9,,,fee schedule,,,474.3,,,percent of total billed charges,,,484.5,,,percent of total billed charges,,,246.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",229.37,,,fee schedule,,,150.87,,,fee schedule,,,150.87,,,fee schedule,,,147.85,,,fee schedule,,,169.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",398.31,,,percent of total billed charges,,,464.1,,,percent of total billed charges,,,169.9,,,fee schedule,,,169.9,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 2 HR LOCUS EA,3114667,CDM,310,RC,81382,CPT,,,,,,inpatient,facility,,,372,156.24,316.2,357.12,,316.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.64,,,percent of total billed charges,,,,,,,,,334.8,,,percent of total billed charges,,,357.12,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,345.96,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 2 HR LOCUS EA,3114667,CDM,310,RC,81382,CPT,,,,,,outpatient,facility,,,372,156.24,100.44,357.12,,316.2,,,percent of total billed charges,,,100.44,,,percent of total billed charges,,,255.94,,,percent of total billed charges,,,250.36,,,percent of total billed charges,,,314.34,,,percent of total billed charges,,,123.68,,,fee schedule,,,323.64,,,percent of total billed charges,,,323.64,,,percent of total billed charges,,,316.2,,,percent of total billed charges,,,357.12,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,126.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",334.8,,,percent of total billed charges,,,123.68,,,fee schedule,,,345.96,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,179.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",166.97,,,fee schedule,,,109.83,,,fee schedule,,,109.83,,,fee schedule,,,107.63,,,fee schedule,,,123.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",290.53,,,percent of total billed charges,,,338.52,,,percent of total billed charges,,,123.68,,,fee schedule,,,123.68,,,fee schedule,,,108.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE TYPING HLA 2 HR ALLE 1 GRP,3114675,CDM,310,RC,81383,CPT,,,,,,inpatient,facility,,,328,137.76,278.8,314.88,,278.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,285.36,,,percent of total billed charges,,,,,,,,,295.2,,,percent of total billed charges,,,314.88,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,305.04,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 2 HR ALLE 1 GRP,3114675,CDM,310,RC,81383,CPT,,,,,,outpatient,facility,,,328,137.76,88.56,314.88,,278.8,,,percent of total billed charges,,,88.56,,,percent of total billed charges,,,225.66,,,percent of total billed charges,,,220.74,,,percent of total billed charges,,,277.16,,,percent of total billed charges,,,109.13,,,fee schedule,,,285.36,,,percent of total billed charges,,,285.36,,,percent of total billed charges,,,278.8,,,percent of total billed charges,,,314.88,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,111.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",295.2,,,percent of total billed charges,,,109.13,,,fee schedule,,,305.04,,,percent of total billed charges,,,311.6,,,percent of total billed charges,,,158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",147.33,,,fee schedule,,,96.91,,,fee schedule,,,96.91,,,fee schedule,,,94.97,,,fee schedule,,,109.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",256.17,,,percent of total billed charges,,,298.48,,,percent of total billed charges,,,109.13,,,fee schedule,,,109.13,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 1,3114683,CDM,310,RC,81400,CPT,,,,,,inpatient,facility,,,192,80.64,163.2,184.32,,163.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.04,,,percent of total billed charges,,,,,,,,,172.8,,,percent of total billed charges,,,184.32,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.56,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 1,3114683,CDM,310,RC,81400,CPT,,,,,,outpatient,facility,,,192,80.64,51.84,192,,163.2,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,132.1,,,percent of total billed charges,,,129.22,,,percent of total billed charges,,,162.24,,,percent of total billed charges,,,63.96,,,fee schedule,,,167.04,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,163.2,,,percent of total billed charges,,,184.32,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,65.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",172.8,,,percent of total billed charges,,,63.96,,,fee schedule,,,178.56,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,92.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",86.35,,,fee schedule,,,192,,,fee schedule,,,192,,,fee schedule,,,192,,,fee schedule,,,63.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",149.95,,,percent of total billed charges,,,174.72,,,percent of total billed charges,,,63.96,,,fee schedule,,,63.96,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 2,3114691,CDM,310,RC,81401,CPT,,,,,,inpatient,facility,,,411,172.62,349.35,394.56,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.57,,,percent of total billed charges,,,,,,,,,369.9,,,percent of total billed charges,,,394.56,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,382.23,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 2,3114691,CDM,310,RC,81401,CPT,,,,,,outpatient,facility,,,411,172.62,110.97,411,,349.35,,,percent of total billed charges,,,110.97,,,percent of total billed charges,,,282.77,,,percent of total billed charges,,,276.6,,,percent of total billed charges,,,347.3,,,percent of total billed charges,,,137,,,fee schedule,,,357.57,,,percent of total billed charges,,,357.57,,,percent of total billed charges,,,349.35,,,percent of total billed charges,,,394.56,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,139.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",369.9,,,percent of total billed charges,,,137,,,fee schedule,,,382.23,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,198.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",184.95,,,fee schedule,,,411,,,fee schedule,,,411,,,fee schedule,,,411,,,fee schedule,,,137,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",320.99,,,percent of total billed charges,,,374.01,,,percent of total billed charges,,,137,,,fee schedule,,,137,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 3,3114709,CDM,310,RC,81402,CPT,,,,,,inpatient,facility,,,451,189.42,383.35,432.96,,383.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.37,,,percent of total billed charges,,,,,,,,,405.9,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 3,3114709,CDM,310,RC,81402,CPT,,,,,,outpatient,facility,,,451,189.42,121.77,451,,383.35,,,percent of total billed charges,,,121.77,,,percent of total billed charges,,,310.29,,,percent of total billed charges,,,303.52,,,percent of total billed charges,,,381.09,,,percent of total billed charges,,,150.33,,,fee schedule,,,392.37,,,percent of total billed charges,,,392.37,,,percent of total billed charges,,,383.35,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,153.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",405.9,,,percent of total billed charges,,,150.33,,,fee schedule,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,217.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",202.95,,,fee schedule,,,451,,,fee schedule,,,451,,,fee schedule,,,451,,,fee schedule,,,150.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",352.23,,,percent of total billed charges,,,410.41,,,percent of total billed charges,,,150.33,,,fee schedule,,,150.33,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 4 NS,3114717,CDM,310,RC,81403,CPT,,,,,,inpatient,facility,,,617,259.14,524.45,592.32,,524.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,536.79,,,percent of total billed charges,,,,,,,,,555.3,,,percent of total billed charges,,,592.32,,,percent of total billed charges,,,586.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,573.81,,,percent of total billed charges,,,586.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 4 NS,3114717,CDM,310,RC,81403,CPT,,,,,,outpatient,facility,,,617,259.14,166.59,617,,524.45,,,percent of total billed charges,,,166.59,,,percent of total billed charges,,,424.5,,,percent of total billed charges,,,415.24,,,percent of total billed charges,,,521.37,,,percent of total billed charges,,,185.2,,,fee schedule,,,536.79,,,percent of total billed charges,,,536.79,,,percent of total billed charges,,,524.45,,,percent of total billed charges,,,592.32,,,percent of total billed charges,,,586.15,,,percent of total billed charges,,,188.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",555.3,,,percent of total billed charges,,,185.2,,,fee schedule,,,573.81,,,percent of total billed charges,,,586.15,,,percent of total billed charges,,,268.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",250.02,,,fee schedule,,,617,,,fee schedule,,,617,,,fee schedule,,,617,,,fee schedule,,,185.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",481.88,,,percent of total billed charges,,,561.47,,,percent of total billed charges,,,185.2,,,fee schedule,,,185.2,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 5,3114725,CDM,310,RC,81404,CPT,,,,,,inpatient,facility,,,825,346.5,701.25,792,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.75,,,percent of total billed charges,,,,,,,,,742.5,,,percent of total billed charges,,,792,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,767.25,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 5,3114725,CDM,310,RC,81404,CPT,,,,,,outpatient,facility,,,825,346.5,222.75,825,,701.25,,,percent of total billed charges,,,222.75,,,percent of total billed charges,,,567.6,,,percent of total billed charges,,,555.22,,,percent of total billed charges,,,697.13,,,percent of total billed charges,,,274.83,,,fee schedule,,,717.75,,,percent of total billed charges,,,717.75,,,percent of total billed charges,,,701.25,,,percent of total billed charges,,,792,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,280.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",742.5,,,percent of total billed charges,,,274.83,,,fee schedule,,,767.25,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,398.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",371.02,,,fee schedule,,,825,,,fee schedule,,,825,,,fee schedule,,,825,,,fee schedule,,,274.83,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",644.32,,,percent of total billed charges,,,750.75,,,percent of total billed charges,,,274.83,,,fee schedule,,,274.83,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 6,3114733,CDM,310,RC,81405,CPT,,,,,,inpatient,facility,,,905,380.1,769.25,868.8,,769.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.35,,,percent of total billed charges,,,,,,,,,814.5,,,percent of total billed charges,,,868.8,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,841.65,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 6,3114733,CDM,310,RC,81405,CPT,,,,,,outpatient,facility,,,905,380.1,244.35,905,,769.25,,,percent of total billed charges,,,244.35,,,percent of total billed charges,,,622.64,,,percent of total billed charges,,,609.06,,,percent of total billed charges,,,764.73,,,percent of total billed charges,,,301.35,,,fee schedule,,,787.35,,,percent of total billed charges,,,787.35,,,percent of total billed charges,,,769.25,,,percent of total billed charges,,,868.8,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,307.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",814.5,,,percent of total billed charges,,,301.35,,,fee schedule,,,841.65,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,436.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",406.82,,,fee schedule,,,905,,,fee schedule,,,905,,,fee schedule,,,905,,,fee schedule,,,301.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",706.8,,,percent of total billed charges,,,823.55,,,percent of total billed charges,,,301.35,,,fee schedule,,,301.35,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 7,3114741,CDM,310,RC,81406,CPT,,,,,,inpatient,facility,,,849,356.58,721.65,815.04,,721.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,738.63,,,percent of total billed charges,,,,,,,,,764.1,,,percent of total billed charges,,,815.04,,,percent of total billed charges,,,806.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,789.57,,,percent of total billed charges,,,806.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 7,3114741,CDM,310,RC,81406,CPT,,,,,,outpatient,facility,,,849,356.58,229.23,849,,721.65,,,percent of total billed charges,,,229.23,,,percent of total billed charges,,,584.11,,,percent of total billed charges,,,571.38,,,percent of total billed charges,,,717.4,,,percent of total billed charges,,,282.88,,,fee schedule,,,738.63,,,percent of total billed charges,,,738.63,,,percent of total billed charges,,,721.65,,,percent of total billed charges,,,815.04,,,percent of total billed charges,,,806.55,,,percent of total billed charges,,,288.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",764.1,,,percent of total billed charges,,,282.88,,,fee schedule,,,789.57,,,percent of total billed charges,,,806.55,,,percent of total billed charges,,,410.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",381.89,,,fee schedule,,,849,,,fee schedule,,,849,,,fee schedule,,,849,,,fee schedule,,,282.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",663.07,,,percent of total billed charges,,,772.59,,,percent of total billed charges,,,282.88,,,fee schedule,,,282.88,,,fee schedule,,,247.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROC PATHOLOGY MOLEC LEVEL 8,3114758,CDM,310,RC,81407,CPT,,,,,,inpatient,facility,,,2539,1066.38,2158.15,2437.44,,2158.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2208.93,,,percent of total billed charges,,,,,,,,,2285.1,,,percent of total billed charges,,,2437.44,,,percent of total billed charges,,,2412.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2361.27,,,percent of total billed charges,,,2412.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 8,3114758,CDM,310,RC,81407,CPT,,,,,,outpatient,facility,,,2539,1066.38,685.53,2539,,2158.15,,,percent of total billed charges,,,685.53,,,percent of total billed charges,,,1746.83,,,percent of total billed charges,,,1708.75,,,percent of total billed charges,,,2145.45,,,percent of total billed charges,,,846.27,,,fee schedule,,,2208.93,,,percent of total billed charges,,,2208.93,,,percent of total billed charges,,,2158.15,,,percent of total billed charges,,,2437.44,,,percent of total billed charges,,,2412.05,,,percent of total billed charges,,,863.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2285.1,,,percent of total billed charges,,,846.27,,,fee schedule,,,2361.27,,,percent of total billed charges,,,2412.05,,,percent of total billed charges,,,1227.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1142.46,,,fee schedule,,,2539,,,fee schedule,,,2539,,,fee schedule,,,2539,,,fee schedule,,,846.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1982.96,,,percent of total billed charges,,,2310.49,,,percent of total billed charges,,,846.27,,,fee schedule,,,846.27,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 9,3114766,CDM,310,RC,81408,CPT,,,,,,inpatient,facility,,,6000,2520,5100,5760,,5100,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5220,,,percent of total billed charges,,,,,,,,,5400,,,percent of total billed charges,,,5760,,,percent of total billed charges,,,5700,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5580,,,percent of total billed charges,,,5700,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 9,3114766,CDM,310,RC,81408,CPT,,,,,,outpatient,facility,,,6000,2520,1620,6000,,5100,,,percent of total billed charges,,,1620,,,percent of total billed charges,,,4128,,,percent of total billed charges,,,4038,,,percent of total billed charges,,,5070,,,percent of total billed charges,,,2000,,,fee schedule,,,5220,,,percent of total billed charges,,,5220,,,percent of total billed charges,,,5100,,,percent of total billed charges,,,5760,,,percent of total billed charges,,,5700,,,percent of total billed charges,,,2040,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5400,,,percent of total billed charges,,,2000,,,fee schedule,,,5580,,,percent of total billed charges,,,5700,,,percent of total billed charges,,,2900,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2700,,,fee schedule,,,6000,,,fee schedule,,,6000,,,fee schedule,,,6000,,,fee schedule,,,2000,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",4686,,,percent of total billed charges,,,5460,,,percent of total billed charges,,,2000,,,fee schedule,,,2000,,,fee schedule,,,,,,,,
LAB SCR AB NMDA RECEPTOR FL,3114824,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,167,70.14,141.95,160.32,,141.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.29,,,percent of total billed charges,,,,,,,,,150.3,,,percent of total billed charges,,,160.32,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,155.31,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB NMDA RECEPTOR FL,3114824,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,167,70.14,10.49,160.32,,141.95,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,114.9,,,percent of total billed charges,,,112.39,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,12.05,,,fee schedule,,,145.29,,,percent of total billed charges,,,145.29,,,percent of total billed charges,,,141.95,,,percent of total billed charges,,,160.32,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",150.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,155.31,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",130.43,,,percent of total billed charges,,,151.97,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NEUTRAL PHOSPHO HEXAGONAL NS,3114832,CDM,305,RC,85598,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NEUTRAL PHOSPHO HEXAGONAL NS,3114832,CDM,305,RC,85598,CPT,,,,,,outpatient,facility,,,64,26.88,15.65,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,17.98,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,18.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,17.98,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,26.07,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.27,,,fee schedule,,,15.97,,,fee schedule,,,15.97,,,fee schedule,,,15.65,,,fee schedule,,,17.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,17.98,,,fee schedule,,,17.98,,,fee schedule,,,,,,,,
LAB THROMBIN TIME PLASMA NS,3114840,CDM,305,RC,85670,CPT,,,,,,inpatient,facility,,,18,7.56,15.3,17.28,,15.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15.66,,,percent of total billed charges,,,,,,,,,16.2,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THROMBIN TIME PLASMA NS,3114840,CDM,305,RC,85670,CPT,,,,,,outpatient,facility,,,18,7.56,4.86,17.28,,15.3,,,percent of total billed charges,,,4.86,,,percent of total billed charges,,,12.38,,,percent of total billed charges,,,12.11,,,percent of total billed charges,,,15.21,,,percent of total billed charges,,,5.77,,,fee schedule,,,15.66,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,15.3,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,5.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,percent of total billed charges,,,5.77,,,fee schedule,,,16.74,,,percent of total billed charges,,,17.1,,,percent of total billed charges,,,8.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.79,,,fee schedule,,,5.12,,,fee schedule,,,5.12,,,fee schedule,,,5.02,,,fee schedule,,,5.77,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",14.06,,,percent of total billed charges,,,16.38,,,percent of total billed charges,,,5.77,,,fee schedule,,,5.77,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE MA CYTO COPY NO ANDSNP BLD NS,3114931,CDM,310,RC,81229,CPT,,,,,,inpatient,facility,,,3480,1461.6,2958,3340.8,,2958,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3027.6,,,percent of total billed charges,,,,,,,,,3132,,,percent of total billed charges,,,3340.8,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3236.4,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MA CYTO COPY NO ANDSNP BLD NS,3114931,CDM,310,RC,81229,CPT,,,,,,outpatient,facility,,,3480,1461.6,939.6,3480,,2958,,,percent of total billed charges,,,939.6,,,percent of total billed charges,,,2394.24,,,percent of total billed charges,,,2342.04,,,percent of total billed charges,,,2940.6,,,percent of total billed charges,,,1160,,,fee schedule,,,3027.6,,,percent of total billed charges,,,3027.6,,,percent of total billed charges,,,2958,,,percent of total billed charges,,,3340.8,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,1183.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3132,,,percent of total billed charges,,,1160,,,fee schedule,,,3236.4,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,1682,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1566,,,fee schedule,,,3480,,,fee schedule,,,3480,,,fee schedule,,,3480,,,fee schedule,,,1160,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",2717.88,,,percent of total billed charges,,,3166.8,,,percent of total billed charges,,,1160,,,fee schedule,,,1160,,,fee schedule,,,,,,,,
LAB GENE MA CYTO COPY NO ANDSNP POC,3114949,CDM,310,RC,81229,CPT,,,,,,inpatient,facility,,,3480,1461.6,2958,3340.8,,2958,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3027.6,,,percent of total billed charges,,,,,,,,,3132,,,percent of total billed charges,,,3340.8,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3236.4,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MA CYTO COPY NO ANDSNP POC,3114949,CDM,310,RC,81229,CPT,,,,,,outpatient,facility,,,3480,1461.6,939.6,3480,,2958,,,percent of total billed charges,,,939.6,,,percent of total billed charges,,,2394.24,,,percent of total billed charges,,,2342.04,,,percent of total billed charges,,,2940.6,,,percent of total billed charges,,,1160,,,fee schedule,,,3027.6,,,percent of total billed charges,,,3027.6,,,percent of total billed charges,,,2958,,,percent of total billed charges,,,3340.8,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,1183.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3132,,,percent of total billed charges,,,1160,,,fee schedule,,,3236.4,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,1682,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1566,,,fee schedule,,,3480,,,fee schedule,,,3480,,,fee schedule,,,3480,,,fee schedule,,,1160,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",2717.88,,,percent of total billed charges,,,3166.8,,,percent of total billed charges,,,1160,,,fee schedule,,,1160,,,fee schedule,,,,,,,,
LAB COUNT BLD RBC AUTO NS,3114956,CDM,305,RC,85041,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD RBC AUTO NS,3114956,CDM,305,RC,85041,CPT,,,,,,outpatient,facility,,,63,26.46,2.12,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,3.02,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,3.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,3.02,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,4.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.08,,,fee schedule,,,2.68,,,fee schedule,,,2.68,,,fee schedule,,,2.63,,,fee schedule,,,3.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,3.02,,,fee schedule,,,3.02,,,fee schedule,,,2.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD HEMATOCRIT NS,3114964,CDM,305,RC,85014,CPT,,,,,,inpatient,facility,,,69,28.98,58.65,66.24,,58.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.03,,,percent of total billed charges,,,,,,,,,62.1,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD HEMATOCRIT NS,3114964,CDM,305,RC,85014,CPT,,,,,,outpatient,facility,,,69,28.98,2.06,66.24,,58.65,,,percent of total billed charges,,,18.63,,,percent of total billed charges,,,47.47,,,percent of total billed charges,,,46.44,,,percent of total billed charges,,,58.3,,,percent of total billed charges,,,2.37,,,fee schedule,,,60.03,,,percent of total billed charges,,,60.03,,,percent of total billed charges,,,58.65,,,percent of total billed charges,,,66.24,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.1,,,percent of total billed charges,,,2.37,,,fee schedule,,,64.17,,,percent of total billed charges,,,65.55,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.89,,,percent of total billed charges,,,62.79,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,2.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COUNT BLD HEMOGLOBIN NS,3114972,CDM,305,RC,85018,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COUNT BLD HEMOGLOBIN NS,3114972,CDM,305,RC,85018,CPT,,,,,,outpatient,facility,,,60,25.2,1.95,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,2.37,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,2.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,2.37,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,3.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3.2,,,fee schedule,,,2.1,,,fee schedule,,,2.1,,,fee schedule,,,2.06,,,fee schedule,,,2.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,2.37,,,fee schedule,,,2.37,,,fee schedule,,,1.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE MGMT ANLYS METHYLATION,3114980,CDM,310,RC,81287,CPT,,,,,,inpatient,facility,,,374,157.08,317.9,359.04,,317.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,325.38,,,percent of total billed charges,,,,,,,,,336.6,,,percent of total billed charges,,,359.04,,,percent of total billed charges,,,355.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,347.82,,,percent of total billed charges,,,355.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MGMT ANLYS METHYLATION,3114980,CDM,310,RC,81287,CPT,,,,,,outpatient,facility,,,374,157.08,100.98,374,,317.9,,,percent of total billed charges,,,100.98,,,percent of total billed charges,,,257.31,,,percent of total billed charges,,,251.7,,,percent of total billed charges,,,316.03,,,percent of total billed charges,,,124.64,,,fee schedule,,,325.38,,,percent of total billed charges,,,325.38,,,percent of total billed charges,,,317.9,,,percent of total billed charges,,,359.04,,,percent of total billed charges,,,355.3,,,percent of total billed charges,,,127.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",336.6,,,percent of total billed charges,,,124.64,,,fee schedule,,,347.82,,,percent of total billed charges,,,355.3,,,percent of total billed charges,,,180.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.26,,,fee schedule,,,374,,,fee schedule,,,374,,,fee schedule,,,374,,,fee schedule,,,124.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",292.09,,,percent of total billed charges,,,340.34,,,percent of total billed charges,,,124.64,,,fee schedule,,,124.64,,,fee schedule,,,,,,,,
LAB DEXAMETHASONE,3114998,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,60,25.2,51,57.6,,51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,52.2,,,percent of total billed charges,,,,,,,,,54,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DEXAMETHASONE,3114998,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,60,25.2,16.2,57.6,,51,,,percent of total billed charges,,,16.2,,,percent of total billed charges,,,41.28,,,percent of total billed charges,,,40.38,,,percent of total billed charges,,,50.7,,,percent of total billed charges,,,18.64,,,fee schedule,,,52.2,,,percent of total billed charges,,,52.2,,,percent of total billed charges,,,51,,,percent of total billed charges,,,57.6,,,percent of total billed charges,,,57,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54,,,percent of total billed charges,,,18.64,,,fee schedule,,,55.8,,,percent of total billed charges,,,57,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.86,,,percent of total billed charges,,,54.6,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB SYPHILIS NS,3115011,CDM,302,RC,86780,CPT,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB SYPHILIS NS,3115011,CDM,302,RC,86780,CPT,,,,,,outpatient,facility,,,40,16.8,10.8,38.4,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,13.24,,,fee schedule,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,13.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36,,,percent of total billed charges,,,13.24,,,fee schedule,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,19.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.87,,,fee schedule,,,11.76,,,fee schedule,,,11.76,,,fee schedule,,,11.52,,,fee schedule,,,13.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,13.24,,,fee schedule,,,13.24,,,fee schedule,,,15.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE MA CYTO COPY NO ANDSNP BLD,3115029,CDM,310,RC,81229,CPT,,,,,,inpatient,facility,,,3480,1461.6,2958,3340.8,,2958,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3027.6,,,percent of total billed charges,,,,,,,,,3132,,,percent of total billed charges,,,3340.8,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3236.4,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MA CYTO COPY NO ANDSNP BLD,3115029,CDM,310,RC,81229,CPT,,,,,,outpatient,facility,,,3480,1461.6,939.6,3480,,2958,,,percent of total billed charges,,,939.6,,,percent of total billed charges,,,2394.24,,,percent of total billed charges,,,2342.04,,,percent of total billed charges,,,2940.6,,,percent of total billed charges,,,1160,,,fee schedule,,,3027.6,,,percent of total billed charges,,,3027.6,,,percent of total billed charges,,,2958,,,percent of total billed charges,,,3340.8,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,1183.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3132,,,percent of total billed charges,,,1160,,,fee schedule,,,3236.4,,,percent of total billed charges,,,3306,,,percent of total billed charges,,,1682,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1566,,,fee schedule,,,3480,,,fee schedule,,,3480,,,fee schedule,,,3480,,,fee schedule,,,1160,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",2717.88,,,percent of total billed charges,,,3166.8,,,percent of total billed charges,,,1160,,,fee schedule,,,1160,,,fee schedule,,,,,,,,
LAB DET IA TRICHOMONAS VAG PRB AMP,3115060,CDM,306,RC,87661,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA TRICHOMONAS VAG PRB AMP,3115060,CDM,306,RC,87661,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
WELLNESS URIC ACID,3115128,CDM,301,RC,,,,,,,,inpatient,facility,,,15,6.3,12.75,14.4,,12.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.05,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS URIC ACID,3115128,CDM,301,RC,,,,,,,,outpatient,facility,,,15,6.3,4.05,15,,12.75,,,percent of total billed charges,,,4.05,,,percent of total billed charges,,,10.32,,,percent of total billed charges,,,10.09,,,percent of total billed charges,,,12.67,,,percent of total billed charges,,,,,,,,,13.05,,,percent of total billed charges,,,13.05,,,percent of total billed charges,,,12.75,,,percent of total billed charges,,,14.4,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,13.5,,,percent of total billed charges,,,,,,,,,13.95,,,percent of total billed charges,,,14.25,,,percent of total billed charges,,,,,,,,,,,,,,,15,,,fee schedule,,,15,,,fee schedule,,,15,,,fee schedule,,,,,,,,,11.71,,,percent of total billed charges,,,13.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA B PERTUSSIS PCR PRB AMP,3115169,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA B PERTUSSIS PCR PRB AMP,3115169,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB B CELLS CD19 COUNT TOTAL NS,3115193,CDM,302,RC,86355,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB B CELLS CD19 COUNT TOTAL NS,3115193,CDM,302,RC,86355,CPT,,,,,,outpatient,facility,,,114,47.88,30.78,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,37.73,,,fee schedule,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.6,,,percent of total billed charges,,,37.73,,,fee schedule,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,46.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA LEGIONELL PNEUM PRB AMP,3115649,CDM,306,RC,87541,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA LEGIONELL PNEUM PRB AMP,3115649,CDM,306,RC,87541,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB POSACONAZOLE,3115664,CDM,301,RC,80187,CPT,,,,,,inpatient,facility,,,118,49.56,100.3,113.28,,100.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.66,,,percent of total billed charges,,,,,,,,,106.2,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB POSACONAZOLE,3115664,CDM,301,RC,80187,CPT,,,,,,outpatient,facility,,,118,49.56,23.59,113.28,,100.3,,,percent of total billed charges,,,31.86,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,79.41,,,percent of total billed charges,,,99.71,,,percent of total billed charges,,,27.11,,,fee schedule,,,102.66,,,percent of total billed charges,,,102.66,,,percent of total billed charges,,,100.3,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,27.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",106.2,,,percent of total billed charges,,,27.11,,,fee schedule,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,39.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.6,,,fee schedule,,,24.07,,,fee schedule,,,24.07,,,fee schedule,,,23.59,,,fee schedule,,,27.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",92.16,,,percent of total billed charges,,,107.38,,,percent of total billed charges,,,27.11,,,fee schedule,,,27.11,,,fee schedule,,,,,,,,
LAB DIGOXIN TOTAL,3115672,CDM,301,RC,80162,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIGOXIN TOTAL,3115672,CDM,301,RC,80162,CPT,,,,,,outpatient,facility,,,53,22.26,11.55,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,13.28,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,13.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,13.28,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,19.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.93,,,fee schedule,,,11.79,,,fee schedule,,,11.79,,,fee schedule,,,11.55,,,fee schedule,,,13.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,13.28,,,fee schedule,,,13.28,,,fee schedule,,,16.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DIGOXIN FREE,3115680,CDM,301,RC,80163,CPT,,,,,,inpatient,facility,,,40,16.8,34,38.4,,34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,34.8,,,percent of total billed charges,,,,,,,,,36,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIGOXIN FREE,3115680,CDM,301,RC,80163,CPT,,,,,,outpatient,facility,,,40,16.8,10.8,38.4,,34,,,percent of total billed charges,,,10.8,,,percent of total billed charges,,,27.52,,,percent of total billed charges,,,26.92,,,percent of total billed charges,,,33.8,,,percent of total billed charges,,,13.28,,,fee schedule,,,34.8,,,percent of total billed charges,,,34.8,,,percent of total billed charges,,,34,,,percent of total billed charges,,,38.4,,,percent of total billed charges,,,38,,,percent of total billed charges,,,13.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36,,,percent of total billed charges,,,13.28,,,fee schedule,,,37.2,,,percent of total billed charges,,,38,,,percent of total billed charges,,,19.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.93,,,fee schedule,,,11.79,,,fee schedule,,,11.79,,,fee schedule,,,11.55,,,fee schedule,,,13.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",31.24,,,percent of total billed charges,,,36.4,,,percent of total billed charges,,,13.28,,,fee schedule,,,13.28,,,fee schedule,,,15.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID VALPROIC TOTAL,3115698,CDM,301,RC,80164,CPT,,,,,,inpatient,facility,,,53,22.26,45.05,50.88,,45.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.11,,,percent of total billed charges,,,,,,,,,47.7,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID VALPROIC TOTAL,3115698,CDM,301,RC,80164,CPT,,,,,,outpatient,facility,,,53,22.26,11.78,50.88,,45.05,,,percent of total billed charges,,,14.31,,,percent of total billed charges,,,36.46,,,percent of total billed charges,,,35.67,,,percent of total billed charges,,,44.78,,,percent of total billed charges,,,13.54,,,fee schedule,,,46.11,,,percent of total billed charges,,,46.11,,,percent of total billed charges,,,45.05,,,percent of total billed charges,,,50.88,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.7,,,percent of total billed charges,,,13.54,,,fee schedule,,,49.29,,,percent of total billed charges,,,50.35,,,percent of total billed charges,,,19.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.28,,,fee schedule,,,12.02,,,fee schedule,,,12.02,,,fee schedule,,,11.78,,,fee schedule,,,13.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",41.39,,,percent of total billed charges,,,48.23,,,percent of total billed charges,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,16.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HPV TYPES RISK HIGH,3115714,CDM,306,RC,87624,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HPV TYPES RISK HIGH,3115714,CDM,306,RC,87624,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,41.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMHST IMCYT MLTPLX PER SPEC NS,3115730,CDM,312,RC,88344,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMHST IMCYT MLTPLX PER SPEC NS,3115730,CDM,312,RC,88344,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB IMHST IMCYT MLTPLX PER SPEC NS,3115730,CDM,312,RC,88344,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO HER2 MANUAL PER SPEC NS,3115748,CDM,312,RC,88360,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO HER2 MANUAL PER SPEC NS,3115748,CDM,312,RC,88360,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO HER2 MANUAL PER SPEC NS,3115748,CDM,312,RC,88360,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO HER2 COMP PER SPEC,3115755,CDM,312,RC,88361,CPT,,,,,,inpatient,facility,,,1028,431.76,873.8,986.88,,873.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,894.36,,,percent of total billed charges,,,,,,,,,925.2,,,percent of total billed charges,,,986.88,,,percent of total billed charges,,,976.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,956.04,,,percent of total billed charges,,,976.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO HER2 COMP PER SPEC,3115755,CDM,312,RC,88361,CPT,,,,,,outpatient,facility,,,1028,431.76,277.56,986.88,,873.8,,,percent of total billed charges,,,277.56,,,percent of total billed charges,,,707.26,,,percent of total billed charges,,,691.84,,,percent of total billed charges,,,868.66,,,percent of total billed charges,,,,,,,,,894.36,,,percent of total billed charges,,,894.36,,,percent of total billed charges,,,873.8,,,percent of total billed charges,,,986.88,,,percent of total billed charges,,,976.6,,,percent of total billed charges,,,,,,,,,925.2,,,percent of total billed charges,,,,,,,,,956.04,,,percent of total billed charges,,,976.6,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,802.87,,,percent of total billed charges,,,935.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO HER2 COMP PER SPEC,3115755,CDM,312,RC,88361,CPT,5673,APC,,,,outpatient,facility,,,1028,1028,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISH PRB STAIN PER SPEC ADDL,3115763,CDM,312,RC,88364,CPT,,,,,,inpatient,facility,,,136,57.12,115.6,130.56,,115.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,118.32,,,percent of total billed charges,,,,,,,,,122.4,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISH PRB STAIN PER SPEC ADDL,3115763,CDM,312,RC,88364,CPT,,,,,,outpatient,facility,,,136,57.12,36.72,136,,115.6,,,percent of total billed charges,,,36.72,,,percent of total billed charges,,,93.57,,,percent of total billed charges,,,91.53,,,percent of total billed charges,,,114.92,,,percent of total billed charges,,,,,,,,,118.32,,,percent of total billed charges,,,118.32,,,percent of total billed charges,,,115.6,,,percent of total billed charges,,,130.56,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,122.4,,,percent of total billed charges,,,,,,,,,126.48,,,percent of total billed charges,,,129.2,,,percent of total billed charges,,,,,,,,,,,,,,,136,,,fee schedule,,,136,,,fee schedule,,,136,,,fee schedule,,,,,,,,,106.22,,,percent of total billed charges,,,123.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ISH PRB STAIN PER SPEC ADDL NS,3115771,CDM,312,RC,88364,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISH PRB STAIN PER SPEC ADDL NS,3115771,CDM,312,RC,88364,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,124,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,,,,,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,124,,,fee schedule,,,124,,,fee schedule,,,124,,,fee schedule,,,,,,,,,96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ISH 1ST PRB STAIN PER SPEC NS,3115789,CDM,312,RC,88365,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISH 1ST PRB STAIN PER SPEC NS,3115789,CDM,312,RC,88365,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ISH 1ST PRB STAIN PER SPEC NS,3115789,CDM,312,RC,88365,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISH 1ST PRB STAIN PER SPEC,3115797,CDM,312,RC,88365,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISH 1ST PRB STAIN PER SPEC,3115797,CDM,312,RC,88365,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ISH 1ST PRB STAIN PER SPEC,3115797,CDM,312,RC,88365,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH COMP 1ST SPEC NS,3115805,CDM,312,RC,88367,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP 1ST SPEC NS,3115805,CDM,312,RC,88367,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP 1ST SPEC NS,3115805,CDM,312,RC,88367,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH MANUAL 1ST SPEC,3115813,CDM,312,RC,88368,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MANUAL 1ST SPEC,3115813,CDM,312,RC,88368,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MANUAL 1ST SPEC,3115813,CDM,312,RC,88368,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH MANUAL 1ST SPEC NS,3115821,CDM,312,RC,88368,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MANUAL 1ST SPEC NS,3115821,CDM,312,RC,88368,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MANUAL 1ST SPEC NS,3115821,CDM,312,RC,88368,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH MANUAL ADDL SPEC,3115839,CDM,312,RC,88369,CPT,,,,,,inpatient,facility,,,295,123.9,250.75,283.2,,250.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,256.65,,,percent of total billed charges,,,,,,,,,265.5,,,percent of total billed charges,,,283.2,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,274.35,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MANUAL ADDL SPEC,3115839,CDM,312,RC,88369,CPT,,,,,,outpatient,facility,,,295,123.9,79.65,295,,250.75,,,percent of total billed charges,,,79.65,,,percent of total billed charges,,,202.96,,,percent of total billed charges,,,198.53,,,percent of total billed charges,,,249.28,,,percent of total billed charges,,,,,,,,,256.65,,,percent of total billed charges,,,256.65,,,percent of total billed charges,,,250.75,,,percent of total billed charges,,,283.2,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,,,,,,,265.5,,,percent of total billed charges,,,,,,,,,274.35,,,percent of total billed charges,,,280.25,,,percent of total billed charges,,,,,,,,,,,,,,,295,,,fee schedule,,,295,,,fee schedule,,,295,,,fee schedule,,,,,,,,,230.4,,,percent of total billed charges,,,268.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MANUAL ADDL SPEC NS,3115847,CDM,312,RC,88369,CPT,,,,,,inpatient,facility,,,101,42.42,85.85,96.96,,85.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.87,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MANUAL ADDL SPEC NS,3115847,CDM,312,RC,88369,CPT,,,,,,outpatient,facility,,,101,42.42,27.27,101,,85.85,,,percent of total billed charges,,,27.27,,,percent of total billed charges,,,69.49,,,percent of total billed charges,,,67.97,,,percent of total billed charges,,,85.34,,,percent of total billed charges,,,,,,,,,87.87,,,percent of total billed charges,,,87.87,,,percent of total billed charges,,,85.85,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,101,,,fee schedule,,,101,,,fee schedule,,,101,,,fee schedule,,,,,,,,,78.88,,,percent of total billed charges,,,91.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP ADDL SPEC NS,3115854,CDM,312,RC,88373,CPT,,,,,,inpatient,facility,,,86,36.12,73.1,82.56,,73.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,74.82,,,percent of total billed charges,,,,,,,,,77.4,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP ADDL SPEC NS,3115854,CDM,312,RC,88373,CPT,,,,,,outpatient,facility,,,86,36.12,23.22,86,,73.1,,,percent of total billed charges,,,23.22,,,percent of total billed charges,,,59.17,,,percent of total billed charges,,,57.88,,,percent of total billed charges,,,72.67,,,percent of total billed charges,,,,,,,,,74.82,,,percent of total billed charges,,,74.82,,,percent of total billed charges,,,73.1,,,percent of total billed charges,,,82.56,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,77.4,,,percent of total billed charges,,,,,,,,,79.98,,,percent of total billed charges,,,81.7,,,percent of total billed charges,,,,,,,,,,,,,,,86,,,fee schedule,,,86,,,fee schedule,,,86,,,fee schedule,,,,,,,,,67.17,,,percent of total billed charges,,,78.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO BX PROS NDL,3115862,CDM,312,RC,G0416,HCPCS,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO BX PROS NDL,3115862,CDM,312,RC,G0416,HCPCS,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB PATH GROSS ANDMICRO BX PROS NDL,3115862,CDM,312,RC,G0416,HCPCS,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB VOLATILE,3115888,CDM,301,RC,84600,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VOLATILE,3115888,CDM,301,RC,84600,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.11,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.11,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,24.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.1,,,fee schedule,,,15.19,,,fee schedule,,,15.19,,,fee schedule,,,14.89,,,fee schedule,,,17.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.11,,,fee schedule,,,17.11,,,fee schedule,,,19.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR VOLATILE,3115896,CDM,301,RC,84600,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR VOLATILE,3115896,CDM,301,RC,84600,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.11,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.11,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,24.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.1,,,fee schedule,,,15.19,,,fee schedule,,,15.19,,,fee schedule,,,14.89,,,fee schedule,,,17.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.11,,,fee schedule,,,17.11,,,fee schedule,,,19.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMHST IMCYT AB 1ST PER SPEC NS,3115904,CDM,312,RC,88342,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMHST IMCYT AB 1ST PER SPEC NS,3115904,CDM,312,RC,88342,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB IMHST IMCYT AB 1ST PER SPEC NS,3115904,CDM,312,RC,88342,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMHST IMCYT AB PER SPEC NS ADDL,3115912,CDM,312,RC,88341,CPT,,,,,,inpatient,facility,,,137,57.54,116.45,131.52,,116.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,119.19,,,percent of total billed charges,,,,,,,,,123.3,,,percent of total billed charges,,,131.52,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,127.41,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMHST IMCYT AB PER SPEC NS ADDL,3115912,CDM,312,RC,88341,CPT,,,,,,outpatient,facility,,,137,57.54,36.99,137,,116.45,,,percent of total billed charges,,,36.99,,,percent of total billed charges,,,94.26,,,percent of total billed charges,,,92.2,,,percent of total billed charges,,,115.77,,,percent of total billed charges,,,,,,,,,119.19,,,percent of total billed charges,,,119.19,,,percent of total billed charges,,,116.45,,,percent of total billed charges,,,131.52,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,,,,,,,123.3,,,percent of total billed charges,,,,,,,,,127.41,,,percent of total billed charges,,,130.15,,,percent of total billed charges,,,,,,,,,,,,,,,137,,,fee schedule,,,137,,,fee schedule,,,137,,,fee schedule,,,,,,,,,107,,,percent of total billed charges,,,124.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA HPV TYPES 16 AND18,3115961,CDM,306,RC,87625,CPT,,,,,,inpatient,facility,,,122,51.24,103.7,117.12,,103.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,106.14,,,percent of total billed charges,,,,,,,,,109.8,,,percent of total billed charges,,,117.12,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,113.46,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HPV TYPES 16 AND18,3115961,CDM,306,RC,87625,CPT,,,,,,outpatient,facility,,,122,51.24,32.94,117.12,,103.7,,,percent of total billed charges,,,32.94,,,percent of total billed charges,,,83.94,,,percent of total billed charges,,,82.11,,,percent of total billed charges,,,103.09,,,percent of total billed charges,,,40.55,,,fee schedule,,,106.14,,,percent of total billed charges,,,106.14,,,percent of total billed charges,,,103.7,,,percent of total billed charges,,,117.12,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,41.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",109.8,,,percent of total billed charges,,,40.55,,,fee schedule,,,113.46,,,percent of total billed charges,,,115.9,,,percent of total billed charges,,,58.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",54.74,,,fee schedule,,,36.01,,,fee schedule,,,36.01,,,fee schedule,,,35.29,,,fee schedule,,,40.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",95.28,,,percent of total billed charges,,,111.02,,,percent of total billed charges,,,40.55,,,fee schedule,,,40.55,,,fee schedule,,,40.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISH MLTPLX PER SPEC,3115987,CDM,312,RC,88366,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISH MLTPLX PER SPEC,3115987,CDM,312,RC,88366,CPT,,,,,,outpatient,facility,,,973,408.66,170.8,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ISH MLTPLX PER SPEC,3115987,CDM,312,RC,88366,CPT,5672,APC,,,,outpatient,facility,,,973,973,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA GI MULT PRB AMP 3 5 TGT,3115995,CDM,306,RC,87505,CPT,,,,,,inpatient,facility,,,385,161.7,327.25,369.6,,327.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,334.95,,,percent of total billed charges,,,,,,,,,346.5,,,percent of total billed charges,,,369.6,,,percent of total billed charges,,,365.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.05,,,percent of total billed charges,,,365.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA GI MULT PRB AMP 3 5 TGT,3115995,CDM,306,RC,87505,CPT,,,,,,outpatient,facility,,,385,161.7,103.95,369.6,,327.25,,,percent of total billed charges,,,103.95,,,percent of total billed charges,,,264.88,,,percent of total billed charges,,,259.1,,,percent of total billed charges,,,325.32,,,percent of total billed charges,,,128.29,,,fee schedule,,,334.95,,,percent of total billed charges,,,334.95,,,percent of total billed charges,,,327.25,,,percent of total billed charges,,,369.6,,,percent of total billed charges,,,365.75,,,percent of total billed charges,,,130.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",346.5,,,percent of total billed charges,,,128.29,,,fee schedule,,,358.05,,,percent of total billed charges,,,365.75,,,percent of total billed charges,,,186.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",173.19,,,fee schedule,,,113.92,,,fee schedule,,,113.92,,,fee schedule,,,111.64,,,fee schedule,,,128.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",300.68,,,percent of total billed charges,,,350.35,,,percent of total billed charges,,,128.29,,,fee schedule,,,128.29,,,fee schedule,,,153.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH COMP MULT SPEC NS,3116001,CDM,312,RC,88374,CPT,,,,,,inpatient,facility,,,650,273,552.5,624,,552.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,565.5,,,percent of total billed charges,,,,,,,,,585,,,percent of total billed charges,,,624,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,604.5,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP MULT SPEC NS,3116001,CDM,312,RC,88374,CPT,,,,,,outpatient,facility,,,650,273,170.8,624,,552.5,,,percent of total billed charges,,,175.5,,,percent of total billed charges,,,447.2,,,percent of total billed charges,,,437.45,,,percent of total billed charges,,,549.25,,,percent of total billed charges,,,,,,,,,565.5,,,percent of total billed charges,,,565.5,,,percent of total billed charges,,,552.5,,,percent of total billed charges,,,624,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,,,,,,,585,,,percent of total billed charges,,,,,,,,,604.5,,,percent of total billed charges,,,617.5,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,507.65,,,percent of total billed charges,,,591.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP MULT SPEC NS,3116001,CDM,312,RC,88374,CPT,5672,APC,,,,outpatient,facility,,,650,650,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB FDP FSP AGG SEMI QN NS,3116035,CDM,305,RC,85362,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FDP FSP AGG SEMI QN NS,3116035,CDM,305,RC,85362,CPT,,,,,,outpatient,facility,,,80,33.6,5.63,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,6.89,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,7.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,6.89,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,9.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.3,,,fee schedule,,,6.12,,,fee schedule,,,6.12,,,fee schedule,,,6,,,fee schedule,,,6.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,6.89,,,fee schedule,,,6.89,,,fee schedule,,,5.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH MAN MULT PER SPEC NS,3116043,CDM,312,RC,88377,CPT,,,,,,inpatient,facility,,,504,211.68,428.4,483.84,,428.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,438.48,,,percent of total billed charges,,,,,,,,,453.6,,,percent of total billed charges,,,483.84,,,percent of total billed charges,,,478.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,468.72,,,percent of total billed charges,,,478.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MAN MULT PER SPEC NS,3116043,CDM,312,RC,88377,CPT,,,,,,outpatient,facility,,,504,211.68,136.08,483.84,,428.4,,,percent of total billed charges,,,136.08,,,percent of total billed charges,,,346.75,,,percent of total billed charges,,,339.19,,,percent of total billed charges,,,425.88,,,percent of total billed charges,,,,,,,,,438.48,,,percent of total billed charges,,,438.48,,,percent of total billed charges,,,428.4,,,percent of total billed charges,,,483.84,,,percent of total billed charges,,,478.8,,,percent of total billed charges,,,,,,,,,453.6,,,percent of total billed charges,,,,,,,,,468.72,,,percent of total billed charges,,,478.8,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,393.62,,,percent of total billed charges,,,458.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH MAN MULT PER SPEC NS,3116043,CDM,312,RC,88377,CPT,5672,APC,,,,outpatient,facility,,,504,504,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID VALPROIC TOTAL NS,3116126,CDM,301,RC,80164,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID VALPROIC TOTAL NS,3116126,CDM,301,RC,80164,CPT,,,,,,outpatient,facility,,,66,27.72,11.78,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,13.54,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,13.54,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,19.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.28,,,fee schedule,,,12.02,,,fee schedule,,,12.02,,,fee schedule,,,11.78,,,fee schedule,,,13.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,16.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ACID VALPROIC FREE,3116134,CDM,301,RC,80165,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ACID VALPROIC FREE,3116134,CDM,301,RC,80165,CPT,,,,,,outpatient,facility,,,66,27.72,11.78,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,13.54,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,13.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,13.54,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,19.63,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.28,,,fee schedule,,,12.02,,,fee schedule,,,12.02,,,fee schedule,,,11.78,,,fee schedule,,,13.54,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,13.54,,,fee schedule,,,13.54,,,fee schedule,,,16.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE TPMT NS,3116142,CDM,310,RC,81335,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TPMT NS,3116142,CDM,310,RC,81335,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB DET IA CANDIDA PRB AMP,3116159,CDM,306,RC,87481,CPT,,,,,,inpatient,facility,,,237,99.54,201.45,227.52,,201.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.19,,,percent of total billed charges,,,,,,,,,213.3,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CANDIDA PRB AMP,3116159,CDM,306,RC,87481,CPT,,,,,,outpatient,facility,,,237,99.54,30.54,227.52,,201.45,,,percent of total billed charges,,,63.99,,,percent of total billed charges,,,163.06,,,percent of total billed charges,,,159.5,,,percent of total billed charges,,,200.26,,,percent of total billed charges,,,35.09,,,fee schedule,,,206.19,,,percent of total billed charges,,,206.19,,,percent of total billed charges,,,201.45,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",213.3,,,percent of total billed charges,,,35.09,,,fee schedule,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",185.1,,,percent of total billed charges,,,215.67,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SMEAR INCL BODIES PARASITE NS,3116241,CDM,306,RC,87207,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SMEAR INCL BODIES PARASITE NS,3116241,CDM,306,RC,87207,CPT,,,,,,outpatient,facility,,,64,26.88,5.21,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,5.99,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,6.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,5.99,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,8.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.09,,,fee schedule,,,5.32,,,fee schedule,,,5.32,,,fee schedule,,,5.21,,,fee schedule,,,5.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,5.99,,,fee schedule,,,5.99,,,fee schedule,,,5.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM HIV1 W HIV 1 AND2,3116316,CDM,306,RC,87389,CPT,,,,,,inpatient,facility,,,87,36.54,73.95,83.52,,73.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,75.69,,,percent of total billed charges,,,,,,,,,78.3,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,80.91,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM HIV1 W HIV 1 AND2,3116316,CDM,306,RC,87389,CPT,,,,,,outpatient,facility,,,87,36.54,20.95,83.52,,73.95,,,percent of total billed charges,,,23.49,,,percent of total billed charges,,,59.86,,,percent of total billed charges,,,58.55,,,percent of total billed charges,,,73.52,,,percent of total billed charges,,,24.08,,,fee schedule,,,75.69,,,percent of total billed charges,,,75.69,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,24.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",78.3,,,percent of total billed charges,,,24.08,,,fee schedule,,,80.91,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,34.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.51,,,fee schedule,,,21.38,,,fee schedule,,,21.38,,,fee schedule,,,20.95,,,fee schedule,,,24.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",67.95,,,percent of total billed charges,,,79.17,,,percent of total billed charges,,,24.08,,,fee schedule,,,24.08,,,fee schedule,,,26.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA HIV 1 QN NS,3116332,CDM,306,RC,87536,CPT,,,,,,inpatient,facility,,,256,107.52,217.6,245.76,,217.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HIV 1 QN NS,3116332,CDM,306,RC,87536,CPT,,,,,,outpatient,facility,,,256,107.52,69.12,245.76,,217.6,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,176.13,,,percent of total billed charges,,,172.29,,,percent of total billed charges,,,216.32,,,percent of total billed charges,,,85.1,,,fee schedule,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,217.6,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,86.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",230.4,,,percent of total billed charges,,,85.1,,,fee schedule,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,123.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",114.89,,,fee schedule,,,75.57,,,fee schedule,,,75.57,,,fee schedule,,,74.06,,,fee schedule,,,85.1,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",199.94,,,percent of total billed charges,,,232.96,,,percent of total billed charges,,,85.1,,,fee schedule,,,85.1,,,fee schedule,,,104.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PH STOOL NS,3116357,CDM,301,RC,83986,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PH STOOL NS,3116357,CDM,301,RC,83986,CPT,,,,,,outpatient,facility,,,72,30.24,1.43,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,3.58,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,3.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,3.58,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,5.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.83,,,fee schedule,,,3.18,,,fee schedule,,,3.18,,,fee schedule,,,3.12,,,fee schedule,,,3.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,3.58,,,fee schedule,,,3.58,,,fee schedule,,,1.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB PARANEOPLASTIC FL,3116365,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,108,45.36,91.8,103.68,,91.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.96,,,percent of total billed charges,,,,,,,,,97.2,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB PARANEOPLASTIC FL,3116365,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,108,45.36,10.49,103.68,,91.8,,,percent of total billed charges,,,29.16,,,percent of total billed charges,,,74.3,,,percent of total billed charges,,,72.68,,,percent of total billed charges,,,91.26,,,percent of total billed charges,,,12.05,,,fee schedule,,,93.96,,,percent of total billed charges,,,93.96,,,percent of total billed charges,,,91.8,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.2,,,percent of total billed charges,,,12.05,,,fee schedule,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",84.35,,,percent of total billed charges,,,98.28,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ARIPIPRAZOLE,3116373,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ARIPIPRAZOLE,3116373,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,62,26.04,16.22,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,18.64,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,18.64,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HSP 70 WB W INTRP,3116381,CDM,301,RC,84181,CPT,,,,,,inpatient,facility,,,174,73.08,147.9,167.04,,147.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.38,,,percent of total billed charges,,,,,,,,,156.6,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,161.82,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HSP 70 WB W INTRP,3116381,CDM,301,RC,84181,CPT,,,,,,outpatient,facility,,,174,73.08,14.82,167.04,,147.9,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,119.71,,,percent of total billed charges,,,117.1,,,percent of total billed charges,,,147.03,,,percent of total billed charges,,,17.03,,,fee schedule,,,151.38,,,percent of total billed charges,,,151.38,,,percent of total billed charges,,,147.9,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",156.6,,,percent of total billed charges,,,17.03,,,fee schedule,,,161.82,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,24.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.99,,,fee schedule,,,15.12,,,fee schedule,,,15.12,,,fee schedule,,,14.82,,,fee schedule,,,17.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",135.89,,,percent of total billed charges,,,158.34,,,percent of total billed charges,,,17.03,,,fee schedule,,,17.03,,,fee schedule,,,20.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE BCR ABL1 BREAKPOINT MIN,3116399,CDM,310,RC,81207,CPT,,,,,,inpatient,facility,,,435,182.7,369.75,417.6,,369.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,378.45,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,417.6,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,404.55,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BCR ABL1 BREAKPOINT MIN,3116399,CDM,310,RC,81207,CPT,,,,,,outpatient,facility,,,435,182.7,117.45,435,,369.75,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.75,,,percent of total billed charges,,,367.57,,,percent of total billed charges,,,144.84,,,fee schedule,,,378.45,,,percent of total billed charges,,,378.45,,,percent of total billed charges,,,369.75,,,percent of total billed charges,,,417.6,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,147.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",391.5,,,percent of total billed charges,,,144.84,,,fee schedule,,,404.55,,,percent of total billed charges,,,413.25,,,percent of total billed charges,,,210.02,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",195.53,,,fee schedule,,,435,,,fee schedule,,,435,,,fee schedule,,,435,,,fee schedule,,,144.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",339.74,,,percent of total billed charges,,,395.85,,,percent of total billed charges,,,144.84,,,fee schedule,,,144.84,,,fee schedule,,,,,,,,
LAB GENE BCR ABL1 REFLEX P210,3116407,CDM,310,RC,81206,CPT,,,,,,inpatient,facility,,,492,206.64,418.2,472.32,,418.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.04,,,percent of total billed charges,,,,,,,,,442.8,,,percent of total billed charges,,,472.32,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,457.56,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BCR ABL1 REFLEX P210,3116407,CDM,310,RC,81206,CPT,,,,,,outpatient,facility,,,492,206.64,132.84,492,,418.2,,,percent of total billed charges,,,132.84,,,percent of total billed charges,,,338.5,,,percent of total billed charges,,,331.12,,,percent of total billed charges,,,415.74,,,percent of total billed charges,,,163.96,,,fee schedule,,,428.04,,,percent of total billed charges,,,428.04,,,percent of total billed charges,,,418.2,,,percent of total billed charges,,,472.32,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,167.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",442.8,,,percent of total billed charges,,,163.96,,,fee schedule,,,457.56,,,percent of total billed charges,,,467.4,,,percent of total billed charges,,,237.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",221.35,,,fee schedule,,,492,,,fee schedule,,,492,,,fee schedule,,,492,,,fee schedule,,,163.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",384.25,,,percent of total billed charges,,,447.72,,,percent of total billed charges,,,163.96,,,fee schedule,,,163.96,,,fee schedule,,,143.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONCENTRATION ANY TYPE IA NS,3116423,CDM,306,RC,87015,CPT,,,,,,inpatient,facility,,,128,53.76,108.8,122.88,,108.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.36,,,percent of total billed charges,,,,,,,,,115.2,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONCENTRATION ANY TYPE IA NS,3116423,CDM,306,RC,87015,CPT,,,,,,outpatient,facility,,,128,53.76,5.34,122.88,,108.8,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,88.06,,,percent of total billed charges,,,86.14,,,percent of total billed charges,,,108.16,,,percent of total billed charges,,,6.68,,,fee schedule,,,111.36,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,108.8,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,6.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",115.2,,,percent of total billed charges,,,6.68,,,fee schedule,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,9.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.02,,,fee schedule,,,5.93,,,fee schedule,,,5.93,,,fee schedule,,,5.81,,,fee schedule,,,6.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.97,,,percent of total billed charges,,,116.48,,,percent of total billed charges,,,6.68,,,fee schedule,,,6.68,,,fee schedule,,,5.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IF PNEUMOCYSTIS NS,3116431,CDM,306,RC,87281,CPT,,,,,,inpatient,facility,,,76,31.92,64.6,72.96,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.12,,,percent of total billed charges,,,,,,,,,68.4,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IF PNEUMOCYSTIS NS,3116431,CDM,306,RC,87281,CPT,,,,,,outpatient,facility,,,76,31.92,10.43,72.96,,64.6,,,percent of total billed charges,,,20.52,,,percent of total billed charges,,,52.29,,,percent of total billed charges,,,51.15,,,percent of total billed charges,,,64.22,,,percent of total billed charges,,,11.98,,,fee schedule,,,66.12,,,percent of total billed charges,,,66.12,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,72.96,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",68.4,,,percent of total billed charges,,,11.98,,,fee schedule,,,70.68,,,percent of total billed charges,,,72.2,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",59.36,,,percent of total billed charges,,,69.16,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE ANLYS MUT CALRETICULIN,3116472,CDM,310,RC,81219,CPT,,,,,,inpatient,facility,,,365,153.3,310.25,350.4,,310.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,317.55,,,percent of total billed charges,,,,,,,,,328.5,,,percent of total billed charges,,,350.4,,,percent of total billed charges,,,346.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,339.45,,,percent of total billed charges,,,346.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE ANLYS MUT CALRETICULIN,3116472,CDM,310,RC,81219,CPT,,,,,,outpatient,facility,,,365,153.3,98.55,365,,310.25,,,percent of total billed charges,,,98.55,,,percent of total billed charges,,,251.12,,,percent of total billed charges,,,245.64,,,percent of total billed charges,,,308.43,,,percent of total billed charges,,,121.63,,,fee schedule,,,317.55,,,percent of total billed charges,,,317.55,,,percent of total billed charges,,,310.25,,,percent of total billed charges,,,350.4,,,percent of total billed charges,,,346.75,,,percent of total billed charges,,,124.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",328.5,,,percent of total billed charges,,,121.63,,,fee schedule,,,339.45,,,percent of total billed charges,,,346.75,,,percent of total billed charges,,,176.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",164.2,,,fee schedule,,,365,,,fee schedule,,,365,,,fee schedule,,,365,,,fee schedule,,,121.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",285.06,,,percent of total billed charges,,,332.15,,,percent of total billed charges,,,121.63,,,fee schedule,,,121.63,,,fee schedule,,,,,,,,
LAB GENE MLH1 METHYLATION,3116506,CDM,310,RC,81288,CPT,,,,,,inpatient,facility,,,577,242.34,490.45,553.92,,490.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,501.99,,,percent of total billed charges,,,,,,,,,519.3,,,percent of total billed charges,,,553.92,,,percent of total billed charges,,,548.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,536.61,,,percent of total billed charges,,,548.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MLH1 METHYLATION,3116506,CDM,310,RC,81288,CPT,,,,,,outpatient,facility,,,577,242.34,155.79,577,,490.45,,,percent of total billed charges,,,155.79,,,percent of total billed charges,,,396.98,,,percent of total billed charges,,,388.32,,,percent of total billed charges,,,487.56,,,percent of total billed charges,,,192.32,,,fee schedule,,,501.99,,,percent of total billed charges,,,501.99,,,percent of total billed charges,,,490.45,,,percent of total billed charges,,,553.92,,,percent of total billed charges,,,548.15,,,percent of total billed charges,,,196.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",519.3,,,percent of total billed charges,,,192.32,,,fee schedule,,,536.61,,,percent of total billed charges,,,548.15,,,percent of total billed charges,,,278.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",259.63,,,fee schedule,,,577,,,fee schedule,,,577,,,fee schedule,,,577,,,fee schedule,,,192.32,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",450.64,,,percent of total billed charges,,,525.07,,,percent of total billed charges,,,192.32,,,fee schedule,,,192.32,,,fee schedule,,,,,,,,
LAB CHROMAT MS NON DRUG QL QN NS,3116514,CDM,301,RC,82542,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS NON DRUG QL QN NS,3116514,CDM,301,RC,82542,CPT,,,,,,outpatient,facility,,,73,30.66,14.06,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,24.09,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,24.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,24.09,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,34.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.52,,,fee schedule,,,21.39,,,fee schedule,,,21.39,,,fee schedule,,,20.96,,,fee schedule,,,24.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,24.09,,,fee schedule,,,24.09,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MS ANDMS TNDM NON DRUG QL QN,3116522,CDM,301,RC,83789,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MS ANDMS TNDM NON DRUG QL QN,3116522,CDM,301,RC,83789,CPT,,,,,,outpatient,facility,,,73,30.66,14.06,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,24.11,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,24.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,24.11,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,34.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.55,,,fee schedule,,,21.41,,,fee schedule,,,21.41,,,fee schedule,,,20.98,,,fee schedule,,,24.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,24.11,,,fee schedule,,,24.11,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HEPATITIS A,3116530,CDM,302,RC,86708,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HEPATITIS A,3116530,CDM,302,RC,86708,CPT,,,,,,outpatient,facility,,,55,23.1,10.78,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,12.39,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,12.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,12.39,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,17.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.73,,,fee schedule,,,11,,,fee schedule,,,11,,,fee schedule,,,10.78,,,fee schedule,,,12.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,12.39,,,fee schedule,,,12.39,,,fee schedule,,,13.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLOMIPRAMINE,3116571,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLOMIPRAMINE,3116571,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,62,26.04,16.22,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,18.64,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,18.64,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE ABL1 VAR KD,3116597,CDM,310,RC,81170,CPT,,,,,,inpatient,facility,,,900,378,765,864,,765,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,783,,,percent of total billed charges,,,,,,,,,810,,,percent of total billed charges,,,864,,,percent of total billed charges,,,855,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,837,,,percent of total billed charges,,,855,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE ABL1 VAR KD,3116597,CDM,310,RC,81170,CPT,,,,,,outpatient,facility,,,900,378,243,900,,765,,,percent of total billed charges,,,243,,,percent of total billed charges,,,619.2,,,percent of total billed charges,,,605.7,,,percent of total billed charges,,,760.5,,,percent of total billed charges,,,300,,,fee schedule,,,783,,,percent of total billed charges,,,783,,,percent of total billed charges,,,765,,,percent of total billed charges,,,864,,,percent of total billed charges,,,855,,,percent of total billed charges,,,306,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",810,,,percent of total billed charges,,,300,,,fee schedule,,,837,,,percent of total billed charges,,,855,,,percent of total billed charges,,,435,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",405,,,fee schedule,,,900,,,fee schedule,,,900,,,fee schedule,,,900,,,fee schedule,,,300,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",702.9,,,percent of total billed charges,,,819,,,percent of total billed charges,,,300,,,fee schedule,,,300,,,fee schedule,,,,,,,,
LAB GENE CEBPA SEQ FULL,3116605,CDM,310,RC,81218,CPT,,,,,,inpatient,facility,,,726,304.92,617.1,696.96,,617.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,631.62,,,percent of total billed charges,,,,,,,,,653.4,,,percent of total billed charges,,,696.96,,,percent of total billed charges,,,689.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,675.18,,,percent of total billed charges,,,689.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CEBPA SEQ FULL,3116605,CDM,310,RC,81218,CPT,,,,,,outpatient,facility,,,726,304.92,196.02,726,,617.1,,,percent of total billed charges,,,196.02,,,percent of total billed charges,,,499.49,,,percent of total billed charges,,,488.6,,,percent of total billed charges,,,613.47,,,percent of total billed charges,,,241.9,,,fee schedule,,,631.62,,,percent of total billed charges,,,631.62,,,percent of total billed charges,,,617.1,,,percent of total billed charges,,,696.96,,,percent of total billed charges,,,689.7,,,percent of total billed charges,,,246.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",653.4,,,percent of total billed charges,,,241.9,,,fee schedule,,,675.18,,,percent of total billed charges,,,689.7,,,percent of total billed charges,,,350.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",326.57,,,fee schedule,,,726,,,fee schedule,,,726,,,fee schedule,,,726,,,fee schedule,,,241.9,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",567.01,,,percent of total billed charges,,,660.66,,,percent of total billed charges,,,241.9,,,fee schedule,,,241.9,,,fee schedule,,,,,,,,
LAB BUSULFAN,3116613,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BUSULFAN,3116613,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,56,23.52,15.12,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,18.64,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,18.64,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE FLT3 VAR TKD,3116662,CDM,310,RC,81246,CPT,,,,,,inpatient,facility,,,249,104.58,211.65,239.04,,211.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,216.63,,,percent of total billed charges,,,,,,,,,224.1,,,percent of total billed charges,,,239.04,,,percent of total billed charges,,,236.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,231.57,,,percent of total billed charges,,,236.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE FLT3 VAR TKD,3116662,CDM,310,RC,81246,CPT,,,,,,outpatient,facility,,,249,104.58,67.23,249,,211.65,,,percent of total billed charges,,,67.23,,,percent of total billed charges,,,171.31,,,percent of total billed charges,,,167.58,,,percent of total billed charges,,,210.41,,,percent of total billed charges,,,83,,,fee schedule,,,216.63,,,percent of total billed charges,,,216.63,,,percent of total billed charges,,,211.65,,,percent of total billed charges,,,239.04,,,percent of total billed charges,,,236.55,,,percent of total billed charges,,,84.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",224.1,,,percent of total billed charges,,,83,,,fee schedule,,,231.57,,,percent of total billed charges,,,236.55,,,percent of total billed charges,,,120.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",112.05,,,fee schedule,,,249,,,fee schedule,,,249,,,fee schedule,,,249,,,fee schedule,,,83,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",194.47,,,percent of total billed charges,,,226.59,,,percent of total billed charges,,,83,,,fee schedule,,,83,,,fee schedule,,,,,,,,
LAB DRG DF ANTD CYCL AMIT DAY 1 2,3116670,CDM,301,RC,80335,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD CYCL AMIT DAY 1 2,3116670,CDM,301,RC,80335,CPT,,,,,,outpatient,facility,,,62,26.04,16.74,62,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,,,,,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,62,,,fee schedule,,,62,,,fee schedule,,,62,,,fee schedule,,,,,,,,,48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,,,,,,,,,,,,,18.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF BENZ DAY 1 12,3116704,CDM,301,RC,80346,CPT,,,,,,inpatient,facility,,,84,35.28,71.4,80.64,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.08,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BENZ DAY 1 12,3116704,CDM,301,RC,80346,CPT,,,,,,outpatient,facility,,,84,35.28,22.68,84,,71.4,,,percent of total billed charges,,,22.68,,,percent of total billed charges,,,57.79,,,percent of total billed charges,,,56.53,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,,,,,,,73.08,,,percent of total billed charges,,,73.08,,,percent of total billed charges,,,71.4,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,84,,,fee schedule,,,84,,,fee schedule,,,84,,,fee schedule,,,,,,,,,65.6,,,percent of total billed charges,,,76.44,,,percent of total billed charges,,,,,,,,,,,,,,,23.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF BENZ CLONAZEPM DAY 1 12,3116720,CDM,301,RC,80346,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BENZ CLONAZEPM DAY 1 12,3116720,CDM,301,RC,80346,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,,,,,,,52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,23.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANTD CYCL DESI DAY 1 2NS,3116837,CDM,301,RC,80335,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD CYCL DESI DAY 1 2NS,3116837,CDM,301,RC,80335,CPT,,,,,,outpatient,facility,,,62,26.04,16.74,62,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,,,,,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,62,,,fee schedule,,,62,,,fee schedule,,,62,,,fee schedule,,,,,,,,,48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,,,,,,,,,,,,,18.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANTD CYCL DOXE DAY 1 2,3116860,CDM,301,RC,80335,CPT,,,,,,inpatient,facility,,,245,102.9,208.25,235.2,,208.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,213.15,,,percent of total billed charges,,,,,,,,,220.5,,,percent of total billed charges,,,235.2,,,percent of total billed charges,,,232.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,227.85,,,percent of total billed charges,,,232.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD CYCL DOXE DAY 1 2,3116860,CDM,301,RC,80335,CPT,,,,,,outpatient,facility,,,245,102.9,18.53,245,,208.25,,,percent of total billed charges,,,66.15,,,percent of total billed charges,,,168.56,,,percent of total billed charges,,,164.88,,,percent of total billed charges,,,207.03,,,percent of total billed charges,,,,,,,,,213.15,,,percent of total billed charges,,,213.15,,,percent of total billed charges,,,208.25,,,percent of total billed charges,,,235.2,,,percent of total billed charges,,,232.75,,,percent of total billed charges,,,,,,,,,220.5,,,percent of total billed charges,,,,,,,,,227.85,,,percent of total billed charges,,,232.75,,,percent of total billed charges,,,,,,,,,,,,,,,245,,,fee schedule,,,245,,,fee schedule,,,245,,,fee schedule,,,,,,,,,191.34,,,percent of total billed charges,,,222.95,,,percent of total billed charges,,,,,,,,,,,,,,,18.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF GOLD DAY 1 3,3116894,CDM,301,RC,80375,CPT,,,,,,inpatient,facility,,,170,71.4,144.5,163.2,,144.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.9,,,percent of total billed charges,,,,,,,,,153,,,percent of total billed charges,,,163.2,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,158.1,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF GOLD DAY 1 3,3116894,CDM,301,RC,80375,CPT,,,,,,outpatient,facility,,,170,71.4,16.89,170,,144.5,,,percent of total billed charges,,,45.9,,,percent of total billed charges,,,116.96,,,percent of total billed charges,,,114.41,,,percent of total billed charges,,,143.65,,,percent of total billed charges,,,,,,,,,147.9,,,percent of total billed charges,,,147.9,,,percent of total billed charges,,,144.5,,,percent of total billed charges,,,163.2,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,,,,,,,153,,,percent of total billed charges,,,,,,,,,158.1,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,170,,,fee schedule,,,170,,,fee schedule,,,170,,,fee schedule,,,,,,,,,132.77,,,percent of total billed charges,,,154.7,,,percent of total billed charges,,,,,,,,,,,,,,,16.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANTD CYCL IMIPRM DAY 1 2,3116928,CDM,301,RC,80335,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD CYCL IMIPRM DAY 1 2,3116928,CDM,301,RC,80335,CPT,,,,,,outpatient,facility,,,344,144.48,18.53,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,18.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANTD CYCL NORT DAY 1 2,3116951,CDM,301,RC,80335,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD CYCL NORT DAY 1 2,3116951,CDM,301,RC,80335,CPT,,,,,,outpatient,facility,,,68,28.56,18.36,68,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,,,,,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,68,,,fee schedule,,,68,,,fee schedule,,,68,,,fee schedule,,,,,,,,,53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,,,,,,,,,,,,,18.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANLG SALICYLATE DAY 1 2,3117017,CDM,301,RC,80329,CPT,,,,,,inpatient,facility,,,180,75.6,153,172.8,,153,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.6,,,percent of total billed charges,,,,,,,,,162,,,percent of total billed charges,,,172.8,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,167.4,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANLG SALICYLATE DAY 1 2,3117017,CDM,301,RC,80329,CPT,,,,,,outpatient,facility,,,180,75.6,16.76,180,,153,,,percent of total billed charges,,,48.6,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,121.14,,,percent of total billed charges,,,152.1,,,percent of total billed charges,,,,,,,,,156.6,,,percent of total billed charges,,,156.6,,,percent of total billed charges,,,153,,,percent of total billed charges,,,172.8,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,167.4,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,,,,,,,180,,,fee schedule,,,180,,,fee schedule,,,180,,,fee schedule,,,,,,,,,140.58,,,percent of total billed charges,,,163.8,,,percent of total billed charges,,,,,,,,,,,,,,,16.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANLG ACETAMINPHN DAY 1 2,3117041,CDM,301,RC,80329,CPT,,,,,,inpatient,facility,,,198,83.16,168.3,190.08,,168.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,172.26,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,190.08,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,184.14,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANLG ACETAMINPHN DAY 1 2,3117041,CDM,301,RC,80329,CPT,,,,,,outpatient,facility,,,198,83.16,16.76,198,,168.3,,,percent of total billed charges,,,53.46,,,percent of total billed charges,,,136.22,,,percent of total billed charges,,,133.25,,,percent of total billed charges,,,167.31,,,percent of total billed charges,,,,,,,,,172.26,,,percent of total billed charges,,,172.26,,,percent of total billed charges,,,168.3,,,percent of total billed charges,,,190.08,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,178.2,,,percent of total billed charges,,,,,,,,,184.14,,,percent of total billed charges,,,188.1,,,percent of total billed charges,,,,,,,,,,,,,,,198,,,fee schedule,,,198,,,fee schedule,,,198,,,fee schedule,,,,,,,,,154.64,,,percent of total billed charges,,,180.18,,,percent of total billed charges,,,,,,,,,,,,,,,16.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ETOH EXCEPT BR DAY,3117074,CDM,301,RC,80320,CPT,,,,,,inpatient,facility,,,132,55.44,112.2,126.72,,112.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.84,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,126.72,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ETOH EXCEPT BR DAY,3117074,CDM,301,RC,80320,CPT,,,,,,outpatient,facility,,,132,55.44,16.23,132,,112.2,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,90.82,,,percent of total billed charges,,,88.84,,,percent of total billed charges,,,111.54,,,percent of total billed charges,,,,,,,,,114.84,,,percent of total billed charges,,,114.84,,,percent of total billed charges,,,112.2,,,percent of total billed charges,,,126.72,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,122.76,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,132,,,fee schedule,,,132,,,fee schedule,,,132,,,fee schedule,,,,,,,,,103.09,,,percent of total billed charges,,,120.12,,,percent of total billed charges,,,,,,,,,,,,,,,16.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ETOH EXCEPT BR DAY NS,3117082,CDM,301,RC,80320,CPT,,,,,,inpatient,facility,,,61,25.62,51.85,58.56,,51.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.07,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ETOH EXCEPT BR DAY NS,3117082,CDM,301,RC,80320,CPT,,,,,,outpatient,facility,,,61,25.62,16.23,61,,51.85,,,percent of total billed charges,,,16.47,,,percent of total billed charges,,,41.97,,,percent of total billed charges,,,41.05,,,percent of total billed charges,,,51.55,,,percent of total billed charges,,,,,,,,,53.07,,,percent of total billed charges,,,53.07,,,percent of total billed charges,,,51.85,,,percent of total billed charges,,,58.56,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,54.9,,,percent of total billed charges,,,,,,,,,56.73,,,percent of total billed charges,,,57.95,,,percent of total billed charges,,,,,,,,,,,,,,,61,,,fee schedule,,,61,,,fee schedule,,,61,,,fee schedule,,,,,,,,,47.64,,,percent of total billed charges,,,55.51,,,percent of total billed charges,,,,,,,,,,,,,,,16.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF AMPH METH DAY 1 2 NS,3117108,CDM,301,RC,80324,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF AMPH METH DAY 1 2 NS,3117108,CDM,301,RC,80324,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BARB PHENOBARB DAY,3117132,CDM,301,RC,80345,CPT,,,,,,inpatient,facility,,,174,73.08,147.9,167.04,,147.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.38,,,percent of total billed charges,,,,,,,,,156.6,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,161.82,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BARB PHENOBARB DAY,3117132,CDM,301,RC,80345,CPT,,,,,,outpatient,facility,,,174,73.08,14.05,174,,147.9,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,119.71,,,percent of total billed charges,,,117.1,,,percent of total billed charges,,,147.03,,,percent of total billed charges,,,,,,,,,151.38,,,percent of total billed charges,,,151.38,,,percent of total billed charges,,,147.9,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,156.6,,,percent of total billed charges,,,,,,,,,161.82,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,,,,,,,174,,,fee schedule,,,174,,,fee schedule,,,174,,,fee schedule,,,,,,,,,135.89,,,percent of total billed charges,,,158.34,,,percent of total billed charges,,,,,,,,,,,,,,,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF BARB URINE DAY,3117181,CDM,301,RC,80345,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BARB URINE DAY,3117181,CDM,301,RC,80345,CPT,,,,,,outpatient,facility,,,67,28.14,14.05,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,,,,,,,52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF COCAINE DAY,3117199,CDM,301,RC,80353,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF COCAINE DAY,3117199,CDM,301,RC,80353,CPT,,,,,,outpatient,facility,,,67,28.14,11.46,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,,,,,,,52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,11.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF MSCL RELAX DAY 1 2,3117256,CDM,301,RC,80369,CPT,,,,,,inpatient,facility,,,154,64.68,130.9,147.84,,130.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.98,,,percent of total billed charges,,,,,,,,,138.6,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF MSCL RELAX DAY 1 2,3117256,CDM,301,RC,80369,CPT,,,,,,outpatient,facility,,,154,64.68,21.62,154,,130.9,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,105.95,,,percent of total billed charges,,,103.64,,,percent of total billed charges,,,130.13,,,percent of total billed charges,,,,,,,,,133.98,,,percent of total billed charges,,,133.98,,,percent of total billed charges,,,130.9,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,138.6,,,percent of total billed charges,,,,,,,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,154,,,fee schedule,,,154,,,fee schedule,,,154,,,fee schedule,,,,,,,,,120.27,,,percent of total billed charges,,,140.14,,,percent of total billed charges,,,,,,,,,,,,,,,21.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF METHADONE DAY NS,3117280,CDM,301,RC,80358,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF METHADONE DAY NS,3117280,CDM,301,RC,80358,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,,,,,,,52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,20.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ALKALOIDS NICOTINE DAY,3117298,CDM,301,RC,80323,CPT,,,,,,inpatient,facility,,,182,76.44,154.7,174.72,,154.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.34,,,percent of total billed charges,,,,,,,,,163.8,,,percent of total billed charges,,,174.72,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,169.26,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ALKALOIDS NICOTINE DAY,3117298,CDM,301,RC,80323,CPT,,,,,,outpatient,facility,,,182,76.44,32.05,182,,154.7,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,125.22,,,percent of total billed charges,,,122.49,,,percent of total billed charges,,,153.79,,,percent of total billed charges,,,,,,,,,158.34,,,percent of total billed charges,,,158.34,,,percent of total billed charges,,,154.7,,,percent of total billed charges,,,174.72,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,163.8,,,percent of total billed charges,,,,,,,,,169.26,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,182,,,fee schedule,,,182,,,fee schedule,,,182,,,fee schedule,,,,,,,,,142.14,,,percent of total billed charges,,,165.62,,,percent of total billed charges,,,,,,,,,,,,,,,32.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF OPIATE DAY 1 PLUS,3117306,CDM,301,RC,80361,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF OPIATE DAY 1 PLUS,3117306,CDM,301,RC,80361,CPT,,,,,,outpatient,facility,,,104,43.68,28.08,104,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,,,,,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,104,,,fee schedule,,,104,,,fee schedule,,,104,,,fee schedule,,,,,,,,,81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,,,,,,,,,,,,,28.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF OXYCODONE DAY,3117314,CDM,301,RC,80365,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF OXYCODONE DAY,3117314,CDM,301,RC,80365,CPT,,,,,,outpatient,facility,,,104,43.68,28.08,104,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,,,,,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,104,,,fee schedule,,,104,,,fee schedule,,,104,,,fee schedule,,,,,,,,,81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF CNFRM AMPH DAY 1 2,3117405,CDM,301,RC,80324,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF CNFRM AMPH DAY 1 2,3117405,CDM,301,RC,80324,CPT,,,,,,outpatient,facility,,,73,30.66,19.71,73,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,,,,,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,73,,,fee schedule,,,73,,,fee schedule,,,73,,,fee schedule,,,,,,,,,57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF CNFRM PHENCYCLDN PCP DAY,3117462,CDM,301,RC,83992,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF CNFRM PHENCYCLDN PCP DAY,3117462,CDM,301,RC,83992,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,40.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG SCR DIRECT OPT OBS ONLY DAY,3117488,CDM,301,RC,80305,CPT,,,,,,inpatient,facility,,,38,15.96,32.3,36.48,,32.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,33.06,,,percent of total billed charges,,,,,,,,,34.2,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SCR DIRECT OPT OBS ONLY DAY,3117488,CDM,301,RC,80305,CPT,,,,,,outpatient,facility,,,38,15.96,10.26,36.48,,32.3,,,percent of total billed charges,,,10.26,,,percent of total billed charges,,,26.14,,,percent of total billed charges,,,25.57,,,percent of total billed charges,,,32.11,,,percent of total billed charges,,,12.6,,,fee schedule,,,33.06,,,percent of total billed charges,,,33.06,,,percent of total billed charges,,,32.3,,,percent of total billed charges,,,36.48,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,12.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.2,,,percent of total billed charges,,,12.6,,,fee schedule,,,35.34,,,percent of total billed charges,,,36.1,,,percent of total billed charges,,,18.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.01,,,fee schedule,,,11.19,,,fee schedule,,,11.19,,,fee schedule,,,10.97,,,fee schedule,,,12.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",29.68,,,percent of total billed charges,,,34.58,,,percent of total billed charges,,,12.6,,,fee schedule,,,12.6,,,fee schedule,,,13.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC DIRECT OPT INST ASST DAY,3117496,CDM,301,RC,80306,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC DIRECT OPT INST ASST DAY,3117496,CDM,301,RC,80306,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.14,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.14,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,24.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.14,,,fee schedule,,,15.22,,,fee schedule,,,15.22,,,fee schedule,,,14.92,,,fee schedule,,,17.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.14,,,fee schedule,,,17.14,,,fee schedule,,,17.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF SULFONYLUREAS DAY 7 PLUS,3117512,CDM,301,RC,80377,CPT,,,,,,inpatient,facility,,,178,74.76,151.3,170.88,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.86,,,percent of total billed charges,,,,,,,,,160.2,,,percent of total billed charges,,,170.88,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.54,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF SULFONYLUREAS DAY 7 PLUS,3117512,CDM,301,RC,80377,CPT,,,,,,outpatient,facility,,,178,74.76,48.06,178,,151.3,,,percent of total billed charges,,,48.06,,,percent of total billed charges,,,122.46,,,percent of total billed charges,,,119.79,,,percent of total billed charges,,,150.41,,,percent of total billed charges,,,,,,,,,154.86,,,percent of total billed charges,,,154.86,,,percent of total billed charges,,,151.3,,,percent of total billed charges,,,170.88,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,160.2,,,percent of total billed charges,,,,,,,,,165.54,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,,,,,,,178,,,fee schedule,,,178,,,fee schedule,,,178,,,fee schedule,,,,,,,,,139.02,,,percent of total billed charges,,,161.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF CANNABINOIDS DAY,3117538,CDM,301,RC,80349,CPT,,,,,,inpatient,facility,,,84,35.28,71.4,80.64,,71.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.08,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF CANNABINOIDS DAY,3117538,CDM,301,RC,80349,CPT,,,,,,outpatient,facility,,,84,35.28,22.68,84,,71.4,,,percent of total billed charges,,,22.68,,,percent of total billed charges,,,57.79,,,percent of total billed charges,,,56.53,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,,,,,,,73.08,,,percent of total billed charges,,,73.08,,,percent of total billed charges,,,71.4,,,percent of total billed charges,,,80.64,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,75.6,,,percent of total billed charges,,,,,,,,,78.12,,,percent of total billed charges,,,79.8,,,percent of total billed charges,,,,,,,,,,,,,,,84,,,fee schedule,,,84,,,fee schedule,,,84,,,fee schedule,,,,,,,,,65.6,,,percent of total billed charges,,,76.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB GENE NRAS VAR EXON 2 AND3 NS,3117561,CDM,310,RC,81311,CPT,,,,,,inpatient,facility,,,888,372.96,754.8,852.48,,754.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,772.56,,,percent of total billed charges,,,,,,,,,799.2,,,percent of total billed charges,,,852.48,,,percent of total billed charges,,,843.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,825.84,,,percent of total billed charges,,,843.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE NRAS VAR EXON 2 AND3 NS,3117561,CDM,310,RC,81311,CPT,,,,,,outpatient,facility,,,888,372.96,239.76,888,,754.8,,,percent of total billed charges,,,239.76,,,percent of total billed charges,,,610.94,,,percent of total billed charges,,,597.62,,,percent of total billed charges,,,750.36,,,percent of total billed charges,,,295.79,,,fee schedule,,,772.56,,,percent of total billed charges,,,772.56,,,percent of total billed charges,,,754.8,,,percent of total billed charges,,,852.48,,,percent of total billed charges,,,843.6,,,percent of total billed charges,,,301.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",799.2,,,percent of total billed charges,,,295.79,,,fee schedule,,,825.84,,,percent of total billed charges,,,843.6,,,percent of total billed charges,,,428.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",399.32,,,fee schedule,,,888,,,fee schedule,,,888,,,fee schedule,,,888,,,fee schedule,,,295.79,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",693.53,,,percent of total billed charges,,,808.08,,,percent of total billed charges,,,295.79,,,fee schedule,,,295.79,,,fee schedule,,,,,,,,
LAB COMPLEMENT AG COMP EA NS,3117611,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,222,93.24,188.7,213.12,,188.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,193.14,,,percent of total billed charges,,,,,,,,,199.8,,,percent of total billed charges,,,213.12,,,percent of total billed charges,,,210.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,206.46,,,percent of total billed charges,,,210.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG COMP EA NS,3117611,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,222,93.24,10.45,213.12,,188.7,,,percent of total billed charges,,,59.94,,,percent of total billed charges,,,152.74,,,percent of total billed charges,,,149.41,,,percent of total billed charges,,,187.59,,,percent of total billed charges,,,12,,,fee schedule,,,193.14,,,percent of total billed charges,,,193.14,,,percent of total billed charges,,,188.7,,,percent of total billed charges,,,213.12,,,percent of total billed charges,,,210.9,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",199.8,,,percent of total billed charges,,,12,,,fee schedule,,,206.46,,,percent of total billed charges,,,210.9,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",173.38,,,percent of total billed charges,,,202.02,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANTIEPILEPTICS DAY 1 3,3117645,CDM,301,RC,80339,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTIEPILEPTICS DAY 1 3,3117645,CDM,301,RC,80339,CPT,,,,,,outpatient,facility,,,344,144.48,17.58,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,17.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS MYOSITIS,3117652,CDM,301,RC,83516,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS MYOSITIS,3117652,CDM,301,RC,83516,CPT,,,,,,outpatient,facility,,,67,28.14,10.04,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,11.53,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,11.53,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA GI MULT PRB 12 25TGT NS,3117660,CDM,306,RC,87507,CPT,,,,,,inpatient,facility,,,1251,525.42,1063.35,1200.96,,1063.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.37,,,percent of total billed charges,,,,,,,,,1125.9,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA GI MULT PRB 12 25TGT NS,3117660,CDM,306,RC,87507,CPT,,,,,,outpatient,facility,,,1251,525.42,337.77,1200.96,,1063.35,,,percent of total billed charges,,,337.77,,,percent of total billed charges,,,860.69,,,percent of total billed charges,,,841.92,,,percent of total billed charges,,,1057.1,,,percent of total billed charges,,,416.78,,,fee schedule,,,1088.37,,,percent of total billed charges,,,1088.37,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,425.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1125.9,,,percent of total billed charges,,,416.78,,,fee schedule,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,604.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.65,,,fee schedule,,,370.1,,,fee schedule,,,370.1,,,fee schedule,,,362.7,,,fee schedule,,,416.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",977.03,,,percent of total billed charges,,,1138.41,,,percent of total billed charges,,,416.78,,,fee schedule,,,416.78,,,fee schedule,,,497.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE MTHFR VAR COMMON,3117686,CDM,310,RC,81291,CPT,,,,,,inpatient,facility,,,197,82.74,167.45,189.12,,167.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.39,,,percent of total billed charges,,,,,,,,,177.3,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MTHFR VAR COMMON,3117686,CDM,310,RC,81291,CPT,,,,,,outpatient,facility,,,197,82.74,53.19,197,,167.45,,,percent of total billed charges,,,53.19,,,percent of total billed charges,,,135.54,,,percent of total billed charges,,,132.58,,,percent of total billed charges,,,166.47,,,percent of total billed charges,,,65.34,,,fee schedule,,,171.39,,,percent of total billed charges,,,171.39,,,percent of total billed charges,,,167.45,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,66.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",177.3,,,percent of total billed charges,,,65.34,,,fee schedule,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,94.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.21,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,65.34,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",153.86,,,percent of total billed charges,,,179.27,,,percent of total billed charges,,,65.34,,,fee schedule,,,65.34,,,fee schedule,,,57.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IF AB STAIN PER SPEC ADDL NS,3117694,CDM,312,RC,88350,CPT,,,,,,inpatient,facility,,,189,79.38,160.65,181.44,,160.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,164.43,,,percent of total billed charges,,,,,,,,,170.1,,,percent of total billed charges,,,181.44,,,percent of total billed charges,,,179.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,175.77,,,percent of total billed charges,,,179.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IF AB STAIN PER SPEC ADDL NS,3117694,CDM,312,RC,88350,CPT,,,,,,outpatient,facility,,,189,79.38,51.03,189,,160.65,,,percent of total billed charges,,,51.03,,,percent of total billed charges,,,130.03,,,percent of total billed charges,,,127.2,,,percent of total billed charges,,,159.7,,,percent of total billed charges,,,,,,,,,164.43,,,percent of total billed charges,,,164.43,,,percent of total billed charges,,,160.65,,,percent of total billed charges,,,181.44,,,percent of total billed charges,,,179.55,,,percent of total billed charges,,,,,,,,,170.1,,,percent of total billed charges,,,,,,,,,175.77,,,percent of total billed charges,,,179.55,,,percent of total billed charges,,,,,,,,,,,,,,,189,,,fee schedule,,,189,,,fee schedule,,,189,,,fee schedule,,,,,,,,,147.61,,,percent of total billed charges,,,171.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB IF AB STAIN INITIAL PER SPEC NS,3117702,CDM,312,RC,88346,CPT,,,,,,inpatient,facility,,,489,205.38,415.65,469.44,,415.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.43,,,percent of total billed charges,,,,,,,,,440.1,,,percent of total billed charges,,,469.44,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.77,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IF AB STAIN INITIAL PER SPEC NS,3117702,CDM,312,RC,88346,CPT,,,,,,outpatient,facility,,,489,205.38,132.03,469.44,,415.65,,,percent of total billed charges,,,132.03,,,percent of total billed charges,,,336.43,,,percent of total billed charges,,,329.1,,,percent of total billed charges,,,413.2,,,percent of total billed charges,,,,,,,,,425.43,,,percent of total billed charges,,,425.43,,,percent of total billed charges,,,415.65,,,percent of total billed charges,,,469.44,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,440.1,,,percent of total billed charges,,,,,,,,,454.77,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,381.91,,,percent of total billed charges,,,444.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB IF AB STAIN INITIAL PER SPEC NS,3117702,CDM,312,RC,88346,CPT,5672,APC,,,,outpatient,facility,,,489,489,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INTERLEUKIN 2 RECEPTOR,3117710,CDM,301,RC,84238,CPT,,,,,,inpatient,facility,,,144,60.48,122.4,138.24,,122.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.28,,,percent of total billed charges,,,,,,,,,129.6,,,percent of total billed charges,,,138.24,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,133.92,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INTERLEUKIN 2 RECEPTOR,3117710,CDM,301,RC,84238,CPT,,,,,,outpatient,facility,,,144,60.48,31.82,138.24,,122.4,,,percent of total billed charges,,,38.88,,,percent of total billed charges,,,99.07,,,percent of total billed charges,,,96.91,,,percent of total billed charges,,,121.68,,,percent of total billed charges,,,36.57,,,fee schedule,,,125.28,,,percent of total billed charges,,,125.28,,,percent of total billed charges,,,122.4,,,percent of total billed charges,,,138.24,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,37.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",129.6,,,percent of total billed charges,,,36.57,,,fee schedule,,,133.92,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,53.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.37,,,fee schedule,,,32.47,,,fee schedule,,,32.47,,,fee schedule,,,31.82,,,fee schedule,,,36.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",112.46,,,percent of total billed charges,,,131.04,,,percent of total billed charges,,,36.57,,,fee schedule,,,36.57,,,fee schedule,,,44.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF FENTANYL DAY,3117728,CDM,301,RC,80354,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF FENTANYL DAY,3117728,CDM,301,RC,80354,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,,,,,,,52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA MYCOBCT TB PRB AMP,3117736,CDM,306,RC,87556,CPT,,,,,,inpatient,facility,,,126,52.92,107.1,120.96,,107.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,109.62,,,percent of total billed charges,,,,,,,,,113.4,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MYCOBCT TB PRB AMP,3117736,CDM,306,RC,87556,CPT,,,,,,outpatient,facility,,,126,52.92,34.02,120.96,,107.1,,,percent of total billed charges,,,34.02,,,percent of total billed charges,,,86.69,,,percent of total billed charges,,,84.8,,,percent of total billed charges,,,106.47,,,percent of total billed charges,,,41.68,,,fee schedule,,,109.62,,,percent of total billed charges,,,109.62,,,percent of total billed charges,,,107.1,,,percent of total billed charges,,,120.96,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,42.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",113.4,,,percent of total billed charges,,,41.68,,,fee schedule,,,117.18,,,percent of total billed charges,,,119.7,,,percent of total billed charges,,,60.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.27,,,fee schedule,,,37.01,,,fee schedule,,,37.01,,,fee schedule,,,36.27,,,fee schedule,,,41.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",98.41,,,percent of total billed charges,,,114.66,,,percent of total billed charges,,,41.68,,,fee schedule,,,41.68,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE BRCA1 AND2 SEQ ANDDUP DEL FULL,3117744,CDM,310,RC,81162,CPT,,,,,,inpatient,facility,,,5475,2299.5,4653.75,5256,,4653.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4763.25,,,percent of total billed charges,,,,,,,,,4927.5,,,percent of total billed charges,,,5256,,,percent of total billed charges,,,5201.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5091.75,,,percent of total billed charges,,,5201.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE BRCA1 AND2 SEQ ANDDUP DEL FULL,3117744,CDM,310,RC,81162,CPT,,,,,,outpatient,facility,,,5475,2299.5,1478.25,5256,,4653.75,,,percent of total billed charges,,,1478.25,,,percent of total billed charges,,,3766.8,,,percent of total billed charges,,,3684.67,,,percent of total billed charges,,,4626.38,,,percent of total billed charges,,,1824.88,,,fee schedule,,,4763.25,,,percent of total billed charges,,,4763.25,,,percent of total billed charges,,,4653.75,,,percent of total billed charges,,,5256,,,percent of total billed charges,,,5201.25,,,percent of total billed charges,,,1861.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4927.5,,,percent of total billed charges,,,1824.88,,,fee schedule,,,5091.75,,,percent of total billed charges,,,5201.25,,,percent of total billed charges,,,2646.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2463.59,,,fee schedule,,,1620.49,,,fee schedule,,,1620.49,,,fee schedule,,,1588.08,,,fee schedule,,,1824.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",4275.97,,,percent of total billed charges,,,4982.25,,,percent of total billed charges,,,1824.88,,,fee schedule,,,1824.88,,,fee schedule,,,1596.77,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM INTERLEUKIN 6 QN,3117769,CDM,301,RC,83529,CPT,,,,,,inpatient,facility,,,109,45.78,92.65,104.64,,92.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.83,,,percent of total billed charges,,,,,,,,,98.1,,,percent of total billed charges,,,104.64,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,101.37,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM INTERLEUKIN 6 QN,3117769,CDM,301,RC,83529,CPT,,,,,,outpatient,facility,,,109,45.78,15.03,104.64,,92.65,,,percent of total billed charges,,,29.43,,,percent of total billed charges,,,74.99,,,percent of total billed charges,,,73.36,,,percent of total billed charges,,,92.11,,,percent of total billed charges,,,17.27,,,fee schedule,,,94.83,,,percent of total billed charges,,,94.83,,,percent of total billed charges,,,92.65,,,percent of total billed charges,,,104.64,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",98.1,,,percent of total billed charges,,,17.27,,,fee schedule,,,101.37,,,percent of total billed charges,,,103.55,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",85.13,,,percent of total billed charges,,,99.19,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB JOHN CUNNINGHAM VIRUS,3117785,CDM,302,RC,86711,CPT,,,,,,inpatient,facility,,,1468,616.56,1247.8,1409.28,,1247.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1277.16,,,percent of total billed charges,,,,,,,,,1321.2,,,percent of total billed charges,,,1409.28,,,percent of total billed charges,,,1394.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1365.24,,,percent of total billed charges,,,1394.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB JOHN CUNNINGHAM VIRUS,3117785,CDM,302,RC,86711,CPT,,,,,,outpatient,facility,,,1468,616.56,14.7,1409.28,,1247.8,,,percent of total billed charges,,,396.36,,,percent of total billed charges,,,1009.98,,,percent of total billed charges,,,987.96,,,percent of total billed charges,,,1240.46,,,percent of total billed charges,,,16.89,,,fee schedule,,,1277.16,,,percent of total billed charges,,,1277.16,,,percent of total billed charges,,,1247.8,,,percent of total billed charges,,,1409.28,,,percent of total billed charges,,,1394.6,,,percent of total billed charges,,,17.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1321.2,,,percent of total billed charges,,,16.89,,,fee schedule,,,1365.24,,,percent of total billed charges,,,1394.6,,,percent of total billed charges,,,24.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.8,,,fee schedule,,,15,,,fee schedule,,,15,,,fee schedule,,,14.7,,,fee schedule,,,16.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1146.51,,,percent of total billed charges,,,1335.88,,,percent of total billed charges,,,16.89,,,fee schedule,,,16.89,,,fee schedule,,,17.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF METHYLENEDIOXYAMPH NS,3117819,CDM,301,RC,80359,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF METHYLENEDIOXYAMPH NS,3117819,CDM,301,RC,80359,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA GI MULT PRB AMP 6 11 TGT,3117827,CDM,306,RC,87506,CPT,,,,,,inpatient,facility,,,789,331.38,670.65,757.44,,670.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,686.43,,,percent of total billed charges,,,,,,,,,710.1,,,percent of total billed charges,,,757.44,,,percent of total billed charges,,,749.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,733.77,,,percent of total billed charges,,,749.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA GI MULT PRB AMP 6 11 TGT,3117827,CDM,306,RC,87506,CPT,,,,,,outpatient,facility,,,789,331.38,213.03,757.44,,670.65,,,percent of total billed charges,,,213.03,,,percent of total billed charges,,,542.83,,,percent of total billed charges,,,531,,,percent of total billed charges,,,666.7,,,percent of total billed charges,,,262.99,,,fee schedule,,,686.43,,,percent of total billed charges,,,686.43,,,percent of total billed charges,,,670.65,,,percent of total billed charges,,,757.44,,,percent of total billed charges,,,749.55,,,percent of total billed charges,,,268.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",710.1,,,percent of total billed charges,,,262.99,,,fee schedule,,,733.77,,,percent of total billed charges,,,749.55,,,percent of total billed charges,,,381.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",355.04,,,fee schedule,,,233.54,,,fee schedule,,,233.54,,,fee schedule,,,228.87,,,fee schedule,,,262.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",616.21,,,percent of total billed charges,,,717.99,,,percent of total billed charges,,,262.99,,,fee schedule,,,262.99,,,fee schedule,,,254.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOMIC ANLY SEQ SO HL 51 PLUS NS,3117835,CDM,310,RC,81455,CPT,,,,,,inpatient,facility,,,8759,3678.78,7445.15,8408.64,,7445.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7620.33,,,percent of total billed charges,,,,,,,,,7883.1,,,percent of total billed charges,,,8408.64,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8145.87,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOMIC ANLY SEQ SO HL 51 PLUS NS,3117835,CDM,310,RC,81455,CPT,,,,,,outpatient,facility,,,8759,3678.78,2364.93,8759,,7445.15,,,percent of total billed charges,,,2364.93,,,percent of total billed charges,,,6026.19,,,percent of total billed charges,,,5894.81,,,percent of total billed charges,,,7401.35,,,percent of total billed charges,,,2919.6,,,fee schedule,,,7620.33,,,percent of total billed charges,,,7620.33,,,percent of total billed charges,,,7445.15,,,percent of total billed charges,,,8408.64,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,2977.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7883.1,,,percent of total billed charges,,,2919.6,,,fee schedule,,,8145.87,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,4233.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3941.46,,,fee schedule,,,8759,,,fee schedule,,,8759,,,fee schedule,,,8759,,,fee schedule,,,2919.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6840.78,,,percent of total billed charges,,,7970.69,,,percent of total billed charges,,,2919.6,,,fee schedule,,,2919.6,,,fee schedule,,,,,,,,
LAB DET IA HSV PRB AMP,3117868,CDM,306,RC,87529,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HSV PRB AMP,3117868,CDM,306,RC,87529,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH COMP MULT PER SPEC,3117876,CDM,312,RC,88374,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP MULT PER SPEC,3117876,CDM,312,RC,88374,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP MULT PER SPEC,3117876,CDM,312,RC,88374,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ANTD SEROTONERG DAY 3 5,3117918,CDM,301,RC,80333,CPT,,,,,,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD SEROTONERG DAY 3 5,3117918,CDM,301,RC,80333,CPT,,,,,,outpatient,facility,,,97,40.74,26.19,97,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,97,,,fee schedule,,,97,,,fee schedule,,,97,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD CYCL DAY 6 PLUS,3117926,CDM,301,RC,80337,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ANTD CYCL DAY 6 PLUS,3117926,CDM,301,RC,80337,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB FETAL CHROMOSOMAL ANEUPLOIDY,3118031,CDM,310,RC,81420,CPT,,,,,,inpatient,facility,,,2278,956.76,1936.3,2186.88,,1936.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1981.86,,,percent of total billed charges,,,,,,,,,2050.2,,,percent of total billed charges,,,2186.88,,,percent of total billed charges,,,2164.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2118.54,,,percent of total billed charges,,,2164.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FETAL CHROMOSOMAL ANEUPLOIDY,3118031,CDM,310,RC,81420,CPT,,,,,,outpatient,facility,,,2278,956.76,615.06,2278,,1936.3,,,percent of total billed charges,,,615.06,,,percent of total billed charges,,,1567.26,,,percent of total billed charges,,,1533.09,,,percent of total billed charges,,,1924.91,,,percent of total billed charges,,,759.05,,,fee schedule,,,1981.86,,,percent of total billed charges,,,1981.86,,,percent of total billed charges,,,1936.3,,,percent of total billed charges,,,2186.88,,,percent of total billed charges,,,2164.1,,,percent of total billed charges,,,774.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2050.2,,,percent of total billed charges,,,759.05,,,fee schedule,,,2118.54,,,percent of total billed charges,,,2164.1,,,percent of total billed charges,,,1100.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1024.72,,,fee schedule,,,2278,,,fee schedule,,,2278,,,fee schedule,,,2278,,,fee schedule,,,759.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1779.12,,,percent of total billed charges,,,2072.98,,,percent of total billed charges,,,759.05,,,fee schedule,,,759.05,,,fee schedule,,,759.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOMIC ANLY SEQ HL 5 50 NS,3118064,CDM,310,RC,81450,CPT,,,,,,inpatient,facility,,,2395,1005.9,2035.75,2299.2,,2035.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2083.65,,,percent of total billed charges,,,,,,,,,2155.5,,,percent of total billed charges,,,2299.2,,,percent of total billed charges,,,2275.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2227.35,,,percent of total billed charges,,,2275.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOMIC ANLY SEQ HL 5 50 NS,3118064,CDM,310,RC,81450,CPT,,,,,,outpatient,facility,,,2395,1005.9,646.65,2395,,2035.75,,,percent of total billed charges,,,646.65,,,percent of total billed charges,,,1647.76,,,percent of total billed charges,,,1611.83,,,percent of total billed charges,,,2023.77,,,percent of total billed charges,,,759.53,,,fee schedule,,,2083.65,,,percent of total billed charges,,,2083.65,,,percent of total billed charges,,,2035.75,,,percent of total billed charges,,,2299.2,,,percent of total billed charges,,,2275.25,,,percent of total billed charges,,,774.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2155.5,,,percent of total billed charges,,,759.53,,,fee schedule,,,2227.35,,,percent of total billed charges,,,2275.25,,,percent of total billed charges,,,1101.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1025.37,,,fee schedule,,,2395,,,fee schedule,,,2395,,,fee schedule,,,2395,,,fee schedule,,,759.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1870.49,,,percent of total billed charges,,,2179.45,,,percent of total billed charges,,,759.53,,,fee schedule,,,759.53,,,fee schedule,,,,,,,,
LAB MORPHO TMR IHC MNL PER SPEC NS,3118080,CDM,312,RC,88360,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO TMR IHC MNL PER SPEC NS,3118080,CDM,312,RC,88360,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO TMR IHC MNL PER SPEC NS,3118080,CDM,312,RC,88360,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PARATHORMONE NS,3118254,CDM,301,RC,83970,CPT,,,,,,inpatient,facility,,,124,52.08,105.4,119.04,,105.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,,,,,,,111.6,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PARATHORMONE NS,3118254,CDM,301,RC,83970,CPT,,,,,,outpatient,facility,,,124,52.08,33.48,119.04,,105.4,,,percent of total billed charges,,,33.48,,,percent of total billed charges,,,85.31,,,percent of total billed charges,,,83.45,,,percent of total billed charges,,,104.78,,,percent of total billed charges,,,41.28,,,fee schedule,,,107.88,,,percent of total billed charges,,,107.88,,,percent of total billed charges,,,105.4,,,percent of total billed charges,,,119.04,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,42.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",111.6,,,percent of total billed charges,,,41.28,,,fee schedule,,,115.32,,,percent of total billed charges,,,117.8,,,percent of total billed charges,,,59.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.73,,,fee schedule,,,36.66,,,fee schedule,,,36.66,,,fee schedule,,,35.93,,,fee schedule,,,41.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",96.84,,,percent of total billed charges,,,112.84,,,percent of total billed charges,,,41.28,,,fee schedule,,,41.28,,,fee schedule,,,50.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COAGULATION TIME ACTIVATED,3118262,CDM,305,RC,85347,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COAGULATION TIME ACTIVATED,3118262,CDM,305,RC,85347,CPT,,,,,,outpatient,facility,,,55,23.1,3.72,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,4.28,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,4.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,4.28,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,6.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",5.78,,,fee schedule,,,3.8,,,fee schedule,,,3.8,,,fee schedule,,,3.72,,,fee schedule,,,4.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,4.28,,,fee schedule,,,4.28,,,fee schedule,,,5.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA LEGIONELL MULT PRB AMP,3118288,CDM,306,RC,87801,CPT,,,,,,inpatient,facility,,,211,88.62,179.35,202.56,,179.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.57,,,percent of total billed charges,,,,,,,,,189.9,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA LEGIONELL MULT PRB AMP,3118288,CDM,306,RC,87801,CPT,,,,,,outpatient,facility,,,211,88.62,56.97,202.56,,179.35,,,percent of total billed charges,,,56.97,,,percent of total billed charges,,,145.17,,,percent of total billed charges,,,142,,,percent of total billed charges,,,178.29,,,percent of total billed charges,,,70.2,,,fee schedule,,,183.57,,,percent of total billed charges,,,183.57,,,percent of total billed charges,,,179.35,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,71.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",189.9,,,percent of total billed charges,,,70.2,,,fee schedule,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,101.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",94.77,,,fee schedule,,,62.34,,,fee schedule,,,62.34,,,fee schedule,,,61.09,,,fee schedule,,,70.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",164.79,,,percent of total billed charges,,,192.01,,,percent of total billed charges,,,70.2,,,fee schedule,,,70.2,,,fee schedule,,,86.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE EGFR VAR COMMON,3118320,CDM,310,RC,81235,CPT,,,,,,inpatient,facility,,,974,409.08,827.9,935.04,,827.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,847.38,,,percent of total billed charges,,,,,,,,,876.6,,,percent of total billed charges,,,935.04,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,905.82,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE EGFR VAR COMMON,3118320,CDM,310,RC,81235,CPT,,,,,,outpatient,facility,,,974,409.08,262.98,974,,827.9,,,percent of total billed charges,,,262.98,,,percent of total billed charges,,,670.11,,,percent of total billed charges,,,655.5,,,percent of total billed charges,,,823.03,,,percent of total billed charges,,,324.58,,,fee schedule,,,847.38,,,percent of total billed charges,,,847.38,,,percent of total billed charges,,,827.9,,,percent of total billed charges,,,935.04,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,331.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",876.6,,,percent of total billed charges,,,324.58,,,fee schedule,,,905.82,,,percent of total billed charges,,,925.3,,,percent of total billed charges,,,470.64,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",438.18,,,fee schedule,,,974,,,fee schedule,,,974,,,fee schedule,,,974,,,fee schedule,,,324.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",760.69,,,percent of total billed charges,,,886.34,,,percent of total billed charges,,,324.58,,,fee schedule,,,324.58,,,fee schedule,,,,,,,,
LAB GENOMIC ANLY SEQ SO 5 50 NS,3118361,CDM,310,RC,81445,CPT,,,,,,inpatient,facility,,,1794,753.48,1524.9,1722.24,,1524.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.78,,,percent of total billed charges,,,,,,,,,1614.6,,,percent of total billed charges,,,1722.24,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1668.42,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOMIC ANLY SEQ SO 5 50 NS,3118361,CDM,310,RC,81445,CPT,,,,,,outpatient,facility,,,1794,753.48,484.38,1794,,1524.9,,,percent of total billed charges,,,484.38,,,percent of total billed charges,,,1234.27,,,percent of total billed charges,,,1207.36,,,percent of total billed charges,,,1515.93,,,percent of total billed charges,,,597.91,,,fee schedule,,,1560.78,,,percent of total billed charges,,,1560.78,,,percent of total billed charges,,,1524.9,,,percent of total billed charges,,,1722.24,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,609.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1614.6,,,percent of total billed charges,,,597.91,,,fee schedule,,,1668.42,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,866.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",807.18,,,fee schedule,,,1794,,,fee schedule,,,1794,,,fee schedule,,,1794,,,fee schedule,,,597.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1401.11,,,percent of total billed charges,,,1632.54,,,percent of total billed charges,,,597.91,,,fee schedule,,,597.91,,,fee schedule,,,,,,,,
LAB IMM IGFBP 3 QN,3118379,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM IGFBP 3 QN,3118379,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,64,26.88,15.03,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,17.27,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,17.27,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF HEROIN METABOLITE DAY,3118387,CDM,301,RC,80356,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF HEROIN METABOLITE DAY,3118387,CDM,301,RC,80356,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS BILE ACIDS FRAC TTL,3118403,CDM,301,RC,82542,CPT,,,,,,inpatient,facility,,,259,108.78,220.15,248.64,,220.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,225.33,,,percent of total billed charges,,,,,,,,,233.1,,,percent of total billed charges,,,248.64,,,percent of total billed charges,,,246.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,240.87,,,percent of total billed charges,,,246.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS BILE ACIDS FRAC TTL,3118403,CDM,301,RC,82542,CPT,,,,,,outpatient,facility,,,259,108.78,14.06,248.64,,220.15,,,percent of total billed charges,,,69.93,,,percent of total billed charges,,,178.19,,,percent of total billed charges,,,174.31,,,percent of total billed charges,,,218.85,,,percent of total billed charges,,,24.09,,,fee schedule,,,225.33,,,percent of total billed charges,,,225.33,,,percent of total billed charges,,,220.15,,,percent of total billed charges,,,248.64,,,percent of total billed charges,,,246.05,,,percent of total billed charges,,,24.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",233.1,,,percent of total billed charges,,,24.09,,,fee schedule,,,240.87,,,percent of total billed charges,,,246.05,,,percent of total billed charges,,,34.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.52,,,fee schedule,,,21.39,,,fee schedule,,,21.39,,,fee schedule,,,20.96,,,fee schedule,,,24.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",202.28,,,percent of total billed charges,,,235.69,,,percent of total billed charges,,,24.09,,,fee schedule,,,24.09,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA HBSAG QL SEMI QN NS,3118502,CDM,306,RC,87340,CPT,,,,,,inpatient,facility,,,231,97.02,196.35,221.76,,196.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,200.97,,,percent of total billed charges,,,,,,,,,207.9,,,percent of total billed charges,,,221.76,,,percent of total billed charges,,,219.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,214.83,,,percent of total billed charges,,,219.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA HBSAG QL SEMI QN NS,3118502,CDM,306,RC,87340,CPT,,,,,,outpatient,facility,,,231,97.02,8.99,221.76,,196.35,,,percent of total billed charges,,,62.37,,,percent of total billed charges,,,158.93,,,percent of total billed charges,,,155.46,,,percent of total billed charges,,,195.19,,,percent of total billed charges,,,10.33,,,fee schedule,,,200.97,,,percent of total billed charges,,,200.97,,,percent of total billed charges,,,196.35,,,percent of total billed charges,,,221.76,,,percent of total billed charges,,,219.45,,,percent of total billed charges,,,10.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",207.9,,,percent of total billed charges,,,10.33,,,fee schedule,,,214.83,,,percent of total billed charges,,,219.45,,,percent of total billed charges,,,14.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.95,,,fee schedule,,,9.17,,,fee schedule,,,9.17,,,fee schedule,,,8.99,,,fee schedule,,,10.33,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",180.41,,,percent of total billed charges,,,210.21,,,percent of total billed charges,,,10.33,,,fee schedule,,,10.33,,,fee schedule,,,12.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HIV 1 ANDHIV 2 RESULT SGL NS,3118551,CDM,302,RC,86703,CPT,,,,,,inpatient,facility,,,289,121.38,245.65,277.44,,245.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,251.43,,,percent of total billed charges,,,,,,,,,260.1,,,percent of total billed charges,,,277.44,,,percent of total billed charges,,,274.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,268.77,,,percent of total billed charges,,,274.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HIV 1 ANDHIV 2 RESULT SGL NS,3118551,CDM,302,RC,86703,CPT,,,,,,outpatient,facility,,,289,121.38,11.93,277.44,,245.65,,,percent of total billed charges,,,78.03,,,percent of total billed charges,,,198.83,,,percent of total billed charges,,,194.5,,,percent of total billed charges,,,244.2,,,percent of total billed charges,,,13.71,,,fee schedule,,,251.43,,,percent of total billed charges,,,251.43,,,percent of total billed charges,,,245.65,,,percent of total billed charges,,,277.44,,,percent of total billed charges,,,274.55,,,percent of total billed charges,,,13.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",260.1,,,percent of total billed charges,,,13.71,,,fee schedule,,,268.77,,,percent of total billed charges,,,274.55,,,percent of total billed charges,,,19.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.51,,,fee schedule,,,12.17,,,fee schedule,,,12.17,,,fee schedule,,,11.93,,,fee schedule,,,13.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",225.71,,,percent of total billed charges,,,262.99,,,percent of total billed charges,,,13.71,,,fee schedule,,,13.71,,,fee schedule,,,12.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF OPIOID ANDOPIATE ANALOG 5 PLUS,3118569,CDM,301,RC,80364,CPT,,,,,,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF OPIOID ANDOPIATE ANALOG 5 PLUS,3118569,CDM,301,RC,80364,CPT,,,,,,outpatient,facility,,,97,40.74,23.86,97,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,97,,,fee schedule,,,97,,,fee schedule,,,97,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,23.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF ETOH BIOMRK URINE 1 2,3118601,CDM,301,RC,80321,CPT,,,,,,inpatient,facility,,,158,66.36,134.3,151.68,,134.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.46,,,percent of total billed charges,,,,,,,,,142.2,,,percent of total billed charges,,,151.68,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.94,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF ETOH BIOMRK URINE 1 2,3118601,CDM,301,RC,80321,CPT,,,,,,outpatient,facility,,,158,66.36,42.66,158,,134.3,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,108.7,,,percent of total billed charges,,,106.33,,,percent of total billed charges,,,133.51,,,percent of total billed charges,,,,,,,,,137.46,,,percent of total billed charges,,,137.46,,,percent of total billed charges,,,134.3,,,percent of total billed charges,,,151.68,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,142.2,,,percent of total billed charges,,,,,,,,,146.94,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,,,,,,,158,,,fee schedule,,,158,,,fee schedule,,,158,,,fee schedule,,,,,,,,,123.4,,,percent of total billed charges,,,143.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF METHYLPHENIDATE DAY,3118619,CDM,301,RC,80360,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF METHYLPHENIDATE DAY,3118619,CDM,301,RC,80360,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,,,,,,,52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT ACANTHAMOEBA,3118759,CDM,306,RC,87081,CPT,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR CULT ACANTHAMOEBA,3118759,CDM,306,RC,87081,CPT,,,,,,outpatient,facility,,,20,8.4,5.16,19.2,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,6.63,,,fee schedule,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,6.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18,,,percent of total billed charges,,,6.63,,,fee schedule,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,9.61,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.95,,,fee schedule,,,5.89,,,fee schedule,,,5.89,,,fee schedule,,,5.77,,,fee schedule,,,6.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,6.63,,,fee schedule,,,6.63,,,fee schedule,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF TRAMADOL,3118767,CDM,301,RC,80373,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF TRAMADOL,3118767,CDM,301,RC,80373,CPT,,,,,,outpatient,facility,,,67,28.14,18.09,67,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,,,,,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,67,,,fee schedule,,,67,,,fee schedule,,,67,,,fee schedule,,,,,,,,,52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA CNS PRB AMP 12 25 TGT,3118775,CDM,306,RC,87483,CPT,,,,,,inpatient,facility,,,1251,525.42,1063.35,1200.96,,1063.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.37,,,percent of total billed charges,,,,,,,,,1125.9,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CNS PRB AMP 12 25 TGT,3118775,CDM,306,RC,87483,CPT,,,,,,outpatient,facility,,,1251,525.42,337.77,1200.96,,1063.35,,,percent of total billed charges,,,337.77,,,percent of total billed charges,,,860.69,,,percent of total billed charges,,,841.92,,,percent of total billed charges,,,1057.1,,,percent of total billed charges,,,416.78,,,fee schedule,,,1088.37,,,percent of total billed charges,,,1088.37,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,425.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1125.9,,,percent of total billed charges,,,416.78,,,fee schedule,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,604.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.65,,,fee schedule,,,370.1,,,fee schedule,,,370.1,,,fee schedule,,,362.7,,,fee schedule,,,416.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",977.03,,,percent of total billed charges,,,1138.41,,,percent of total billed charges,,,416.78,,,fee schedule,,,416.78,,,fee schedule,,,501.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA CMV QN,3118791,CDM,306,RC,87497,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA CMV QN,3118791,CDM,306,RC,87497,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,123.84,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,42.84,,,fee schedule,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",116.1,,,percent of total billed charges,,,42.84,,,fee schedule,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,38.04,,,fee schedule,,,38.04,,,fee schedule,,,37.28,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,52.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA PERTUSSIS MULT PRB AMP,3118809,CDM,306,RC,87801,CPT,,,,,,inpatient,facility,,,211,88.62,179.35,202.56,,179.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,183.57,,,percent of total billed charges,,,,,,,,,189.9,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA PERTUSSIS MULT PRB AMP,3118809,CDM,306,RC,87801,CPT,,,,,,outpatient,facility,,,211,88.62,56.97,202.56,,179.35,,,percent of total billed charges,,,56.97,,,percent of total billed charges,,,145.17,,,percent of total billed charges,,,142,,,percent of total billed charges,,,178.29,,,percent of total billed charges,,,70.2,,,fee schedule,,,183.57,,,percent of total billed charges,,,183.57,,,percent of total billed charges,,,179.35,,,percent of total billed charges,,,202.56,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,71.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",189.9,,,percent of total billed charges,,,70.2,,,fee schedule,,,196.23,,,percent of total billed charges,,,200.45,,,percent of total billed charges,,,101.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",94.77,,,fee schedule,,,62.34,,,fee schedule,,,62.34,,,fee schedule,,,61.09,,,fee schedule,,,70.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",164.79,,,percent of total billed charges,,,192.01,,,percent of total billed charges,,,70.2,,,fee schedule,,,70.2,,,fee schedule,,,86.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOMIC ANLY SEQ SO 5 50,3118890,CDM,310,RC,81445,CPT,,,,,,inpatient,facility,,,1794,753.48,1524.9,1722.24,,1524.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1560.78,,,percent of total billed charges,,,,,,,,,1614.6,,,percent of total billed charges,,,1722.24,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1668.42,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOMIC ANLY SEQ SO 5 50,3118890,CDM,310,RC,81445,CPT,,,,,,outpatient,facility,,,1794,753.48,484.38,1794,,1524.9,,,percent of total billed charges,,,484.38,,,percent of total billed charges,,,1234.27,,,percent of total billed charges,,,1207.36,,,percent of total billed charges,,,1515.93,,,percent of total billed charges,,,597.91,,,fee schedule,,,1560.78,,,percent of total billed charges,,,1560.78,,,percent of total billed charges,,,1524.9,,,percent of total billed charges,,,1722.24,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,609.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1614.6,,,percent of total billed charges,,,597.91,,,fee schedule,,,1668.42,,,percent of total billed charges,,,1704.3,,,percent of total billed charges,,,866.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",807.18,,,fee schedule,,,1794,,,fee schedule,,,1794,,,fee schedule,,,1794,,,fee schedule,,,597.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1401.11,,,percent of total billed charges,,,1632.54,,,percent of total billed charges,,,597.91,,,fee schedule,,,597.91,,,fee schedule,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 4,3118999,CDM,310,RC,81403,CPT,,,,,,inpatient,facility,,,556,233.52,472.6,533.76,,472.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.72,,,percent of total billed charges,,,,,,,,,500.4,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC LEVEL 4,3118999,CDM,310,RC,81403,CPT,,,,,,outpatient,facility,,,556,233.52,150.12,556,,472.6,,,percent of total billed charges,,,150.12,,,percent of total billed charges,,,382.53,,,percent of total billed charges,,,374.19,,,percent of total billed charges,,,469.82,,,percent of total billed charges,,,185.2,,,fee schedule,,,483.72,,,percent of total billed charges,,,483.72,,,percent of total billed charges,,,472.6,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,188.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",500.4,,,percent of total billed charges,,,185.2,,,fee schedule,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,268.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",250.02,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,185.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",434.24,,,percent of total billed charges,,,505.96,,,percent of total billed charges,,,185.2,,,fee schedule,,,185.2,,,fee schedule,,,,,,,,
LAB ALBUMIN OTHER SOURCE QN EA,3119047,CDM,301,RC,82042,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALBUMIN OTHER SOURCE QN EA,3119047,CDM,301,RC,82042,CPT,,,,,,outpatient,facility,,,58,24.36,6.35,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,7.78,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,7.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,7.78,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,11.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.5,,,fee schedule,,,6.91,,,fee schedule,,,6.91,,,fee schedule,,,6.77,,,fee schedule,,,7.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,7.78,,,fee schedule,,,7.78,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALBUMIN OTHER SOURCE QN EA NS,3119054,CDM,301,RC,82042,CPT,,,,,,inpatient,facility,,,24,10.08,20.4,23.04,,20.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20.88,,,percent of total billed charges,,,,,,,,,21.6,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALBUMIN OTHER SOURCE QN EA NS,3119054,CDM,301,RC,82042,CPT,,,,,,outpatient,facility,,,24,10.08,6.35,23.04,,20.4,,,percent of total billed charges,,,6.48,,,percent of total billed charges,,,16.51,,,percent of total billed charges,,,16.15,,,percent of total billed charges,,,20.28,,,percent of total billed charges,,,7.78,,,fee schedule,,,20.88,,,percent of total billed charges,,,20.88,,,percent of total billed charges,,,20.4,,,percent of total billed charges,,,23.04,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,7.94,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.6,,,percent of total billed charges,,,7.78,,,fee schedule,,,22.32,,,percent of total billed charges,,,22.8,,,percent of total billed charges,,,11.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.5,,,fee schedule,,,6.91,,,fee schedule,,,6.91,,,fee schedule,,,6.77,,,fee schedule,,,7.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",18.74,,,percent of total billed charges,,,21.84,,,percent of total billed charges,,,7.78,,,fee schedule,,,7.78,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALLG IGE QN SEMI QN CRUDE EA,3119062,CDM,302,RC,86003,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALLG IGE QN SEMI QN CRUDE EA,3119062,CDM,302,RC,86003,CPT,,,,,,outpatient,facility,,,56,23.52,4.55,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.22,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.22,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,7.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.05,,,fee schedule,,,4.64,,,fee schedule,,,4.64,,,fee schedule,,,4.55,,,fee schedule,,,5.22,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.22,,,fee schedule,,,5.22,,,fee schedule,,,5.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALLG IGE QN SEMI QN CRUDE EA NS,3119070,CDM,302,RC,86003,CPT,,,,,,inpatient,facility,,,55,23.1,46.75,52.8,,46.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.85,,,percent of total billed charges,,,,,,,,,49.5,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALLG IGE QN SEMI QN CRUDE EA NS,3119070,CDM,302,RC,86003,CPT,,,,,,outpatient,facility,,,55,23.1,4.55,52.8,,46.75,,,percent of total billed charges,,,14.85,,,percent of total billed charges,,,37.84,,,percent of total billed charges,,,37.01,,,percent of total billed charges,,,46.48,,,percent of total billed charges,,,5.22,,,fee schedule,,,47.85,,,percent of total billed charges,,,47.85,,,percent of total billed charges,,,46.75,,,percent of total billed charges,,,52.8,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,5.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",49.5,,,percent of total billed charges,,,5.22,,,fee schedule,,,51.15,,,percent of total billed charges,,,52.25,,,percent of total billed charges,,,7.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.05,,,fee schedule,,,4.64,,,fee schedule,,,4.64,,,fee schedule,,,4.55,,,fee schedule,,,5.22,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",42.95,,,percent of total billed charges,,,50.05,,,percent of total billed charges,,,5.22,,,fee schedule,,,5.22,,,fee schedule,,,5.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF PREGABALIN,3119120,CDM,301,RC,80366,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF PREGABALIN,3119120,CDM,301,RC,80366,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA TRICHOMON VAG PRB AMP NS,3119211,CDM,306,RC,87661,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA TRICHOMON VAG PRB AMP NS,3119211,CDM,306,RC,87661,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,35.09,,,fee schedule,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",99.9,,,percent of total billed charges,,,35.09,,,fee schedule,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF BUPRENORPHINE DAY NS,3119260,CDM,301,RC,80348,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BUPRENORPHINE DAY NS,3119260,CDM,301,RC,80348,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF KETAMN ANDNORKETMN DAY,3119294,CDM,301,RC,80357,CPT,,,,,,inpatient,facility,,,145,60.9,123.25,139.2,,123.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.15,,,percent of total billed charges,,,,,,,,,130.5,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.85,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF KETAMN ANDNORKETMN DAY,3119294,CDM,301,RC,80357,CPT,,,,,,outpatient,facility,,,145,60.9,39.15,145,,123.25,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,,99.76,,,percent of total billed charges,,,97.58,,,percent of total billed charges,,,122.52,,,percent of total billed charges,,,,,,,,,126.15,,,percent of total billed charges,,,126.15,,,percent of total billed charges,,,123.25,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,130.5,,,percent of total billed charges,,,,,,,,,134.85,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,,,,,,,145,,,fee schedule,,,145,,,fee schedule,,,145,,,fee schedule,,,,,,,,,113.25,,,percent of total billed charges,,,131.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF STIMULANTS SYN DAY,3119310,CDM,301,RC,80371,CPT,,,,,,inpatient,facility,,,160,67.2,136,153.6,,136,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.2,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF STIMULANTS SYN DAY,3119310,CDM,301,RC,80371,CPT,,,,,,outpatient,facility,,,160,67.2,43.2,160,,136,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,110.08,,,percent of total billed charges,,,107.68,,,percent of total billed charges,,,135.2,,,percent of total billed charges,,,,,,,,,139.2,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,136,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,160,,,fee schedule,,,160,,,fee schedule,,,160,,,fee schedule,,,,,,,,,124.96,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ALLG IGE QN SEMI QN EA,3119377,CDM,302,RC,86008,CPT,,,,,,inpatient,facility,,,64,26.88,54.4,61.44,,54.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.68,,,percent of total billed charges,,,,,,,,,57.6,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALLG IGE QN SEMI QN EA,3119377,CDM,302,RC,86008,CPT,,,,,,outpatient,facility,,,64,26.88,15.6,61.44,,54.4,,,percent of total billed charges,,,17.28,,,percent of total billed charges,,,44.03,,,percent of total billed charges,,,43.07,,,percent of total billed charges,,,54.08,,,percent of total billed charges,,,17.93,,,fee schedule,,,55.68,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,54.4,,,percent of total billed charges,,,61.44,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.6,,,percent of total billed charges,,,17.93,,,fee schedule,,,59.52,,,percent of total billed charges,,,60.8,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.98,,,percent of total billed charges,,,58.24,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,19.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB USTEKINUMAB,3119385,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,226,94.92,192.1,216.96,,192.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,196.62,,,percent of total billed charges,,,,,,,,,203.4,,,percent of total billed charges,,,216.96,,,percent of total billed charges,,,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,210.18,,,percent of total billed charges,,,214.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB USTEKINUMAB,3119385,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,226,94.92,16.22,216.96,,192.1,,,percent of total billed charges,,,61.02,,,percent of total billed charges,,,155.49,,,percent of total billed charges,,,152.1,,,percent of total billed charges,,,190.97,,,percent of total billed charges,,,18.64,,,fee schedule,,,196.62,,,percent of total billed charges,,,196.62,,,percent of total billed charges,,,192.1,,,percent of total billed charges,,,216.96,,,percent of total billed charges,,,214.7,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",203.4,,,percent of total billed charges,,,18.64,,,fee schedule,,,210.18,,,percent of total billed charges,,,214.7,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",176.51,,,percent of total billed charges,,,205.66,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG IGD SERUM EA,3119526,CDM,301,RC,82784,CPT,,,,,,inpatient,facility,,,63,26.46,53.55,60.48,,53.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,54.81,,,percent of total billed charges,,,,,,,,,56.7,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG IGD SERUM EA,3119526,CDM,301,RC,82784,CPT,,,,,,outpatient,facility,,,63,26.46,8.09,60.48,,53.55,,,percent of total billed charges,,,17.01,,,percent of total billed charges,,,43.34,,,percent of total billed charges,,,42.4,,,percent of total billed charges,,,53.23,,,percent of total billed charges,,,9.3,,,fee schedule,,,54.81,,,percent of total billed charges,,,54.81,,,percent of total billed charges,,,53.55,,,percent of total billed charges,,,60.48,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,9.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.7,,,percent of total billed charges,,,9.3,,,fee schedule,,,58.59,,,percent of total billed charges,,,59.85,,,percent of total billed charges,,,13.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.56,,,fee schedule,,,8.26,,,fee schedule,,,8.26,,,fee schedule,,,8.09,,,fee schedule,,,9.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",49.2,,,percent of total billed charges,,,57.33,,,percent of total billed charges,,,9.3,,,fee schedule,,,9.3,,,fee schedule,,,11.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMMUNOFIXATION EP CRYOGLOBULIN,3119534,CDM,302,RC,86334,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMMUNOFIXATION EP CRYOGLOBULIN,3119534,CDM,302,RC,86334,CPT,,,,,,outpatient,facility,,,68,28.56,18.36,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,22.34,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,22.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,22.34,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,32.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",30.16,,,fee schedule,,,19.84,,,fee schedule,,,19.84,,,fee schedule,,,19.44,,,fee schedule,,,22.34,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,22.34,,,fee schedule,,,22.34,,,fee schedule,,,27.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG IGG SERUM EA,3119542,CDM,301,RC,82784,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG IGG SERUM EA,3119542,CDM,301,RC,82784,CPT,,,,,,outpatient,facility,,,56,23.52,8.09,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,9.3,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,9.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,9.3,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,13.49,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",12.56,,,fee schedule,,,8.26,,,fee schedule,,,8.26,,,fee schedule,,,8.09,,,fee schedule,,,9.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,9.3,,,fee schedule,,,9.3,,,fee schedule,,,11.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROC PATHOLOGY MOLEC HEA RBC,3119559,CDM,310,RC,81403,CPT,,,,,,inpatient,facility,,,556,233.52,472.6,533.76,,472.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.72,,,percent of total billed charges,,,,,,,,,500.4,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROC PATHOLOGY MOLEC HEA RBC,3119559,CDM,310,RC,81403,CPT,,,,,,outpatient,facility,,,556,233.52,150.12,556,,472.6,,,percent of total billed charges,,,150.12,,,percent of total billed charges,,,382.53,,,percent of total billed charges,,,374.19,,,percent of total billed charges,,,469.82,,,percent of total billed charges,,,185.2,,,fee schedule,,,483.72,,,percent of total billed charges,,,483.72,,,percent of total billed charges,,,472.6,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,188.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",500.4,,,percent of total billed charges,,,185.2,,,fee schedule,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,268.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",250.02,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,185.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",434.24,,,percent of total billed charges,,,505.96,,,percent of total billed charges,,,185.2,,,fee schedule,,,185.2,,,fee schedule,,,,,,,,
LAB HANTAVIRUS,3119575,CDM,302,RC,86790,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HANTAVIRUS,3119575,CDM,302,RC,86790,CPT,,,,,,outpatient,facility,,,102,42.84,11.21,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,12.88,,,fee schedule,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",91.8,,,percent of total billed charges,,,12.88,,,fee schedule,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THYROGLOBULIN FNA,3119583,CDM,301,RC,84432,CPT,,,,,,inpatient,facility,,,82,34.44,69.7,78.72,,69.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.34,,,percent of total billed charges,,,,,,,,,73.8,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THYROGLOBULIN FNA,3119583,CDM,301,RC,84432,CPT,,,,,,outpatient,facility,,,82,34.44,13.97,78.72,,69.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,55.19,,,percent of total billed charges,,,69.29,,,percent of total billed charges,,,16.06,,,fee schedule,,,71.34,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,69.7,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,16.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",73.8,,,percent of total billed charges,,,16.06,,,fee schedule,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,23.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.68,,,fee schedule,,,14.26,,,fee schedule,,,14.26,,,fee schedule,,,13.97,,,fee schedule,,,16.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.04,,,percent of total billed charges,,,74.62,,,percent of total billed charges,,,16.06,,,fee schedule,,,16.06,,,fee schedule,,,19.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH COMP 1ST SPEC,3119617,CDM,312,RC,88367,CPT,,,,,,inpatient,facility,,,973,408.66,827.05,934.08,,827.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,846.51,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP 1ST SPEC,3119617,CDM,312,RC,88367,CPT,,,,,,outpatient,facility,,,973,408.66,262.71,934.08,,827.05,,,percent of total billed charges,,,262.71,,,percent of total billed charges,,,669.42,,,percent of total billed charges,,,654.83,,,percent of total billed charges,,,822.18,,,percent of total billed charges,,,,,,,,,846.51,,,percent of total billed charges,,,846.51,,,percent of total billed charges,,,827.05,,,percent of total billed charges,,,934.08,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,875.7,,,percent of total billed charges,,,,,,,,,904.89,,,percent of total billed charges,,,924.35,,,percent of total billed charges,,,,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,359.46,,,fee schedule,,,,,,,,,759.91,,,percent of total billed charges,,,885.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP 1ST SPEC,3119617,CDM,312,RC,88367,CPT,5673,APC,,,,outpatient,facility,,,973,973,176.06,531.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,374.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,366.8,,,fee schedule,,,,,,,,,,,,,,,531.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",495.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,366.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,366.8,,,fee schedule,,,366.8,,,fee schedule,,,176.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MORPHO ISH COMP ADDL SPEC,3119625,CDM,312,RC,88373,CPT,,,,,,inpatient,facility,,,553,232.26,470.05,530.88,,470.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.11,,,percent of total billed charges,,,,,,,,,497.7,,,percent of total billed charges,,,530.88,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,514.29,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MORPHO ISH COMP ADDL SPEC,3119625,CDM,312,RC,88373,CPT,,,,,,outpatient,facility,,,553,232.26,149.31,553,,470.05,,,percent of total billed charges,,,149.31,,,percent of total billed charges,,,380.46,,,percent of total billed charges,,,372.17,,,percent of total billed charges,,,467.28,,,percent of total billed charges,,,,,,,,,481.11,,,percent of total billed charges,,,481.11,,,percent of total billed charges,,,470.05,,,percent of total billed charges,,,530.88,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,497.7,,,percent of total billed charges,,,,,,,,,514.29,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,553,,,fee schedule,,,553,,,fee schedule,,,553,,,fee schedule,,,,,,,,,431.89,,,percent of total billed charges,,,503.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS LEUKOTRIENE,3119658,CDM,301,RC,82542,CPT,,,,,,inpatient,facility,,,325,136.5,276.25,312,,276.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.75,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,312,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,302.25,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS LEUKOTRIENE,3119658,CDM,301,RC,82542,CPT,,,,,,outpatient,facility,,,325,136.5,14.06,312,,276.25,,,percent of total billed charges,,,87.75,,,percent of total billed charges,,,223.6,,,percent of total billed charges,,,218.72,,,percent of total billed charges,,,274.63,,,percent of total billed charges,,,24.09,,,fee schedule,,,282.75,,,percent of total billed charges,,,282.75,,,percent of total billed charges,,,276.25,,,percent of total billed charges,,,312,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,24.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",292.5,,,percent of total billed charges,,,24.09,,,fee schedule,,,302.25,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,34.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.52,,,fee schedule,,,21.39,,,fee schedule,,,21.39,,,fee schedule,,,20.96,,,fee schedule,,,24.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",253.82,,,percent of total billed charges,,,295.75,,,percent of total billed charges,,,24.09,,,fee schedule,,,24.09,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB TREPONEMA PALLIDUM CONF,3119666,CDM,302,RC,86780,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB TREPONEMA PALLIDUM CONF,3119666,CDM,302,RC,86780,CPT,,,,,,outpatient,facility,,,74,31.08,11.52,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,13.24,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,13.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,13.24,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,19.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.87,,,fee schedule,,,11.76,,,fee schedule,,,11.76,,,fee schedule,,,11.52,,,fee schedule,,,13.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,13.24,,,fee schedule,,,13.24,,,fee schedule,,,15.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF THIOPURINE DAY 1 3,3119674,CDM,301,RC,80375,CPT,,,,,,inpatient,facility,,,160,67.2,136,153.6,,136,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.2,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF THIOPURINE DAY 1 3,3119674,CDM,301,RC,80375,CPT,,,,,,outpatient,facility,,,160,67.2,16.89,160,,136,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,110.08,,,percent of total billed charges,,,107.68,,,percent of total billed charges,,,135.2,,,percent of total billed charges,,,,,,,,,139.2,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,136,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,160,,,fee schedule,,,160,,,fee schedule,,,160,,,fee schedule,,,,,,,,,124.96,,,percent of total billed charges,,,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,16.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA VIRUS ZIKA PRB AMP,3119682,CDM,306,RC,87662,CPT,,,,,,inpatient,facility,,,200,84,170,192,,170,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174,,,percent of total billed charges,,,,,,,,,180,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA VIRUS ZIKA PRB AMP,3119682,CDM,306,RC,87662,CPT,,,,,,outpatient,facility,,,200,84,44.65,192,,170,,,percent of total billed charges,,,54,,,percent of total billed charges,,,137.6,,,percent of total billed charges,,,134.6,,,percent of total billed charges,,,169,,,percent of total billed charges,,,51.31,,,fee schedule,,,174,,,percent of total billed charges,,,174,,,percent of total billed charges,,,170,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,52.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",180,,,percent of total billed charges,,,51.31,,,fee schedule,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,74.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.27,,,fee schedule,,,45.56,,,fee schedule,,,45.56,,,fee schedule,,,44.65,,,fee schedule,,,51.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",156.2,,,percent of total billed charges,,,182,,,percent of total billed charges,,,51.31,,,fee schedule,,,51.31,,,fee schedule,,,55.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA LEGIONELL PRB AMP,3119773,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA LEGIONELL PRB AMP,3119773,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GROWTH STIMULATION GENE 2,3119781,CDM,301,RC,83006,CPT,,,,,,inpatient,facility,,,227,95.34,192.95,217.92,,192.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.49,,,percent of total billed charges,,,,,,,,,204.3,,,percent of total billed charges,,,217.92,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.11,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GROWTH STIMULATION GENE 2,3119781,CDM,301,RC,83006,CPT,,,,,,outpatient,facility,,,227,95.34,26.27,227,,192.95,,,percent of total billed charges,,,61.29,,,percent of total billed charges,,,156.18,,,percent of total billed charges,,,152.77,,,percent of total billed charges,,,191.81,,,percent of total billed charges,,,75.6,,,fee schedule,,,197.49,,,percent of total billed charges,,,197.49,,,percent of total billed charges,,,192.95,,,percent of total billed charges,,,217.92,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,77.11,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",204.3,,,percent of total billed charges,,,75.6,,,fee schedule,,,211.11,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,109.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.06,,,fee schedule,,,227,,,fee schedule,,,227,,,fee schedule,,,227,,,fee schedule,,,75.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",177.29,,,percent of total billed charges,,,206.57,,,percent of total billed charges,,,75.6,,,fee schedule,,,75.6,,,fee schedule,,,26.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING IF ANTISERUM EA NS,3119799,CDM,306,RC,87140,CPT,,,,,,inpatient,facility,,,56,23.52,47.6,53.76,,47.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,48.72,,,percent of total billed charges,,,,,,,,,50.4,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING IF ANTISERUM EA NS,3119799,CDM,306,RC,87140,CPT,,,,,,outpatient,facility,,,56,23.52,4.44,53.76,,47.6,,,percent of total billed charges,,,15.12,,,percent of total billed charges,,,38.53,,,percent of total billed charges,,,37.69,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,5.57,,,fee schedule,,,48.72,,,percent of total billed charges,,,48.72,,,percent of total billed charges,,,47.6,,,percent of total billed charges,,,53.76,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,5.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.4,,,percent of total billed charges,,,5.57,,,fee schedule,,,52.08,,,percent of total billed charges,,,53.2,,,percent of total billed charges,,,8.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.52,,,fee schedule,,,4.95,,,fee schedule,,,4.95,,,fee schedule,,,4.85,,,fee schedule,,,5.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",43.74,,,percent of total billed charges,,,50.96,,,percent of total billed charges,,,5.57,,,fee schedule,,,5.57,,,fee schedule,,,4.44,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HAPTOGLOBIN QN NS,3119807,CDM,301,RC,83010,CPT,,,,,,inpatient,facility,,,59,24.78,50.15,56.64,,50.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,51.33,,,percent of total billed charges,,,,,,,,,53.1,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HAPTOGLOBIN QN NS,3119807,CDM,301,RC,83010,CPT,,,,,,outpatient,facility,,,59,24.78,10.95,56.64,,50.15,,,percent of total billed charges,,,15.93,,,percent of total billed charges,,,40.59,,,percent of total billed charges,,,39.71,,,percent of total billed charges,,,49.85,,,percent of total billed charges,,,12.58,,,fee schedule,,,51.33,,,percent of total billed charges,,,51.33,,,percent of total billed charges,,,50.15,,,percent of total billed charges,,,56.64,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,12.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",53.1,,,percent of total billed charges,,,12.58,,,fee schedule,,,54.87,,,percent of total billed charges,,,56.05,,,percent of total billed charges,,,18.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.98,,,fee schedule,,,11.17,,,fee schedule,,,11.17,,,fee schedule,,,10.95,,,fee schedule,,,12.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",46.08,,,percent of total billed charges,,,53.69,,,percent of total billed charges,,,12.58,,,fee schedule,,,12.58,,,fee schedule,,,15.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB APOLIPOPROTEIN A1 EA NS,3119815,CDM,301,RC,82172,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB APOLIPOPROTEIN A1 EA NS,3119815,CDM,301,RC,82172,CPT,,,,,,outpatient,facility,,,77,32.34,18.36,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,21.09,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,21.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,21.09,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,30.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",28.47,,,fee schedule,,,18.73,,,fee schedule,,,18.73,,,fee schedule,,,18.36,,,fee schedule,,,21.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,21.09,,,fee schedule,,,21.09,,,fee schedule,,,18.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB BILIRUBIN TOTAL NS,3119823,CDM,301,RC,82247,CPT,,,,,,inpatient,facility,,,58,24.36,49.3,55.68,,49.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,50.46,,,percent of total billed charges,,,,,,,,,52.2,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB BILIRUBIN TOTAL NS,3119823,CDM,301,RC,82247,CPT,,,,,,outpatient,facility,,,58,24.36,4.37,55.68,,49.3,,,percent of total billed charges,,,15.66,,,percent of total billed charges,,,39.9,,,percent of total billed charges,,,39.03,,,percent of total billed charges,,,49.01,,,percent of total billed charges,,,5.02,,,fee schedule,,,50.46,,,percent of total billed charges,,,50.46,,,percent of total billed charges,,,49.3,,,percent of total billed charges,,,55.68,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,5.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.2,,,percent of total billed charges,,,5.02,,,fee schedule,,,53.94,,,percent of total billed charges,,,55.1,,,percent of total billed charges,,,7.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.78,,,fee schedule,,,4.46,,,fee schedule,,,4.46,,,fee schedule,,,4.37,,,fee schedule,,,5.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",45.3,,,percent of total billed charges,,,52.78,,,percent of total billed charges,,,5.02,,,fee schedule,,,5.02,,,fee schedule,,,5.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ZINC TRANSPORTER,3119849,CDM,302,RC,86341,CPT,,,,,,inpatient,facility,,,240,100.8,204,230.4,,204,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,208.8,,,percent of total billed charges,,,,,,,,,216,,,percent of total billed charges,,,230.4,,,percent of total billed charges,,,228,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,223.2,,,percent of total billed charges,,,228,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ZINC TRANSPORTER,3119849,CDM,302,RC,86341,CPT,,,,,,outpatient,facility,,,240,100.8,20.51,230.4,,204,,,percent of total billed charges,,,64.8,,,percent of total billed charges,,,165.12,,,percent of total billed charges,,,161.52,,,percent of total billed charges,,,202.8,,,percent of total billed charges,,,23.57,,,fee schedule,,,208.8,,,percent of total billed charges,,,208.8,,,percent of total billed charges,,,204,,,percent of total billed charges,,,230.4,,,percent of total billed charges,,,228,,,percent of total billed charges,,,24.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",216,,,percent of total billed charges,,,23.57,,,fee schedule,,,223.2,,,percent of total billed charges,,,228,,,percent of total billed charges,,,34.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.82,,,fee schedule,,,20.93,,,fee schedule,,,20.93,,,fee schedule,,,20.51,,,fee schedule,,,23.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",187.44,,,percent of total billed charges,,,218.4,,,percent of total billed charges,,,23.57,,,fee schedule,,,23.57,,,fee schedule,,,24.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENOMIC ANLY SEQ SO HL 51 PLUS,3119864,CDM,310,RC,81455,CPT,,,,,,inpatient,facility,,,8759,3678.78,7445.15,8408.64,,7445.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7620.33,,,percent of total billed charges,,,,,,,,,7883.1,,,percent of total billed charges,,,8408.64,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8145.87,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOMIC ANLY SEQ SO HL 51 PLUS,3119864,CDM,310,RC,81455,CPT,,,,,,outpatient,facility,,,8759,3678.78,2364.93,8759,,7445.15,,,percent of total billed charges,,,2364.93,,,percent of total billed charges,,,6026.19,,,percent of total billed charges,,,5894.81,,,percent of total billed charges,,,7401.35,,,percent of total billed charges,,,2919.6,,,fee schedule,,,7620.33,,,percent of total billed charges,,,7620.33,,,percent of total billed charges,,,7445.15,,,percent of total billed charges,,,8408.64,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,2977.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7883.1,,,percent of total billed charges,,,2919.6,,,fee schedule,,,8145.87,,,percent of total billed charges,,,8321.05,,,percent of total billed charges,,,4233.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3941.46,,,fee schedule,,,8759,,,fee schedule,,,8759,,,fee schedule,,,8759,,,fee schedule,,,2919.6,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",6840.78,,,percent of total billed charges,,,7970.69,,,percent of total billed charges,,,2919.6,,,fee schedule,,,2919.6,,,fee schedule,,,,,,,,
LAB GENOMIC ANLY SEQ HL 5 50,3119872,CDM,310,RC,81450,CPT,,,,,,inpatient,facility,,,2279,957.18,1937.15,2187.84,,1937.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1982.73,,,percent of total billed charges,,,,,,,,,2051.1,,,percent of total billed charges,,,2187.84,,,percent of total billed charges,,,2165.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2119.47,,,percent of total billed charges,,,2165.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENOMIC ANLY SEQ HL 5 50,3119872,CDM,310,RC,81450,CPT,,,,,,outpatient,facility,,,2279,957.18,615.33,2279,,1937.15,,,percent of total billed charges,,,615.33,,,percent of total billed charges,,,1567.95,,,percent of total billed charges,,,1533.77,,,percent of total billed charges,,,1925.75,,,percent of total billed charges,,,759.53,,,fee schedule,,,1982.73,,,percent of total billed charges,,,1982.73,,,percent of total billed charges,,,1937.15,,,percent of total billed charges,,,2187.84,,,percent of total billed charges,,,2165.05,,,percent of total billed charges,,,774.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2051.1,,,percent of total billed charges,,,759.53,,,fee schedule,,,2119.47,,,percent of total billed charges,,,2165.05,,,percent of total billed charges,,,1101.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1025.37,,,fee schedule,,,2279,,,fee schedule,,,2279,,,fee schedule,,,2279,,,fee schedule,,,759.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1779.9,,,percent of total billed charges,,,2073.89,,,percent of total billed charges,,,759.53,,,fee schedule,,,759.53,,,fee schedule,,,,,,,,
LAB VEDOLIZUMAB,3119880,CDM,301,RC,80280,CPT,,,,,,inpatient,facility,,,325,136.5,276.25,312,,276.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,282.75,,,percent of total billed charges,,,,,,,,,292.5,,,percent of total billed charges,,,312,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,302.25,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB VEDOLIZUMAB,3119880,CDM,301,RC,80280,CPT,,,,,,outpatient,facility,,,325,136.5,33.57,312,,276.25,,,percent of total billed charges,,,87.75,,,percent of total billed charges,,,223.6,,,percent of total billed charges,,,218.72,,,percent of total billed charges,,,274.63,,,percent of total billed charges,,,38.57,,,fee schedule,,,282.75,,,percent of total billed charges,,,282.75,,,percent of total billed charges,,,276.25,,,percent of total billed charges,,,312,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,39.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",292.5,,,percent of total billed charges,,,38.57,,,fee schedule,,,302.25,,,percent of total billed charges,,,308.75,,,percent of total billed charges,,,55.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.07,,,fee schedule,,,34.25,,,fee schedule,,,34.25,,,fee schedule,,,33.57,,,fee schedule,,,38.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",253.82,,,percent of total billed charges,,,295.75,,,percent of total billed charges,,,38.57,,,fee schedule,,,38.57,,,fee schedule,,,,,,,,
LAB DET AG IA IMM ENZ FUNGITELL NS,3119898,CDM,306,RC,87449,CPT,,,,,,inpatient,facility,,,157,65.94,133.45,150.72,,133.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,136.59,,,percent of total billed charges,,,,,,,,,141.3,,,percent of total billed charges,,,150.72,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.01,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ FUNGITELL NS,3119898,CDM,306,RC,87449,CPT,,,,,,outpatient,facility,,,157,65.94,10.43,150.72,,133.45,,,percent of total billed charges,,,42.39,,,percent of total billed charges,,,108.02,,,percent of total billed charges,,,105.66,,,percent of total billed charges,,,132.66,,,percent of total billed charges,,,11.98,,,fee schedule,,,136.59,,,percent of total billed charges,,,136.59,,,percent of total billed charges,,,133.45,,,percent of total billed charges,,,150.72,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",141.3,,,percent of total billed charges,,,11.98,,,fee schedule,,,146.01,,,percent of total billed charges,,,149.15,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",122.62,,,percent of total billed charges,,,142.87,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT TYPING ID SEQ NUC ACID NS,3119930,CDM,306,RC,87153,CPT,,,,,,inpatient,facility,,,347,145.74,294.95,333.12,,294.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,301.89,,,percent of total billed charges,,,,,,,,,312.3,,,percent of total billed charges,,,333.12,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,322.71,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT TYPING ID SEQ NUC ACID NS,3119930,CDM,306,RC,87153,CPT,,,,,,outpatient,facility,,,347,145.74,93.69,333.12,,294.95,,,percent of total billed charges,,,93.69,,,percent of total billed charges,,,238.74,,,percent of total billed charges,,,233.53,,,percent of total billed charges,,,293.21,,,percent of total billed charges,,,115.36,,,fee schedule,,,301.89,,,percent of total billed charges,,,301.89,,,percent of total billed charges,,,294.95,,,percent of total billed charges,,,333.12,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,117.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",312.3,,,percent of total billed charges,,,115.36,,,fee schedule,,,322.71,,,percent of total billed charges,,,329.65,,,percent of total billed charges,,,167.27,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",155.74,,,fee schedule,,,102.44,,,fee schedule,,,102.44,,,fee schedule,,,100.39,,,fee schedule,,,115.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",271.01,,,percent of total billed charges,,,315.77,,,percent of total billed charges,,,115.36,,,fee schedule,,,115.36,,,fee schedule,,,144.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISH MLTPLX PER SPEC NS,3119948,CDM,312,RC,88366,CPT,,,,,,inpatient,facility,,,489,205.38,415.65,469.44,,415.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,425.43,,,percent of total billed charges,,,,,,,,,440.1,,,percent of total billed charges,,,469.44,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,454.77,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISH MLTPLX PER SPEC NS,3119948,CDM,312,RC,88366,CPT,,,,,,outpatient,facility,,,489,205.38,132.03,469.44,,415.65,,,percent of total billed charges,,,132.03,,,percent of total billed charges,,,336.43,,,percent of total billed charges,,,329.1,,,percent of total billed charges,,,413.2,,,percent of total billed charges,,,,,,,,,425.43,,,percent of total billed charges,,,425.43,,,percent of total billed charges,,,415.65,,,percent of total billed charges,,,469.44,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,440.1,,,percent of total billed charges,,,,,,,,,454.77,,,percent of total billed charges,,,464.55,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,381.91,,,percent of total billed charges,,,444.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB ISH MLTPLX PER SPEC NS,3119948,CDM,312,RC,88366,CPT,5672,APC,,,,outpatient,facility,,,489,489,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROMAT MS IODINE QL QN,3120300,CDM,301,RC,82542,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS IODINE QL QN,3120300,CDM,301,RC,82542,CPT,,,,,,outpatient,facility,,,73,30.66,14.06,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,24.09,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,24.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,24.09,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,34.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.52,,,fee schedule,,,21.39,,,fee schedule,,,21.39,,,fee schedule,,,20.96,,,fee schedule,,,24.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,24.09,,,fee schedule,,,24.09,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE DPYD VAR COMMON NS,3120326,CDM,310,RC,81232,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE DPYD VAR COMMON NS,3120326,CDM,310,RC,81232,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB AB VIRUS HEPATITIS E IGG,3120391,CDM,302,RC,86790,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB VIRUS HEPATITIS E IGG,3120391,CDM,302,RC,86790,CPT,,,,,,outpatient,facility,,,71,29.82,11.21,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,12.88,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,12.88,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF AMPH METH MCNIUM DAY 1 2,3120417,CDM,301,RC,80324,CPT,,,,,,inpatient,facility,,,83,34.86,70.55,79.68,,70.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,72.21,,,percent of total billed charges,,,,,,,,,74.7,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF AMPH METH MCNIUM DAY 1 2,3120417,CDM,301,RC,80324,CPT,,,,,,outpatient,facility,,,83,34.86,22.41,83,,70.55,,,percent of total billed charges,,,22.41,,,percent of total billed charges,,,57.1,,,percent of total billed charges,,,55.86,,,percent of total billed charges,,,70.13,,,percent of total billed charges,,,,,,,,,72.21,,,percent of total billed charges,,,72.21,,,percent of total billed charges,,,70.55,,,percent of total billed charges,,,79.68,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,74.7,,,percent of total billed charges,,,,,,,,,77.19,,,percent of total billed charges,,,78.85,,,percent of total billed charges,,,,,,,,,,,,,,,83,,,fee schedule,,,83,,,fee schedule,,,83,,,fee schedule,,,,,,,,,64.82,,,percent of total billed charges,,,75.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG DF COCAINE MECONIUM,3120425,CDM,301,RC,80353,CPT,,,,,,inpatient,facility,,,149,62.58,126.65,143.04,,126.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,129.63,,,percent of total billed charges,,,,,,,,,134.1,,,percent of total billed charges,,,143.04,,,percent of total billed charges,,,141.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,138.57,,,percent of total billed charges,,,141.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF COCAINE MECONIUM,3120425,CDM,301,RC,80353,CPT,,,,,,outpatient,facility,,,149,62.58,11.46,149,,126.65,,,percent of total billed charges,,,40.23,,,percent of total billed charges,,,102.51,,,percent of total billed charges,,,100.28,,,percent of total billed charges,,,125.91,,,percent of total billed charges,,,,,,,,,129.63,,,percent of total billed charges,,,129.63,,,percent of total billed charges,,,126.65,,,percent of total billed charges,,,143.04,,,percent of total billed charges,,,141.55,,,percent of total billed charges,,,,,,,,,134.1,,,percent of total billed charges,,,,,,,,,138.57,,,percent of total billed charges,,,141.55,,,percent of total billed charges,,,,,,,,,,,,,,,149,,,fee schedule,,,149,,,fee schedule,,,149,,,fee schedule,,,,,,,,,116.37,,,percent of total billed charges,,,135.59,,,percent of total billed charges,,,,,,,,,,,,,,,11.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF METHADONE MECONIUM DAY,3120433,CDM,301,RC,80358,CPT,,,,,,inpatient,facility,,,165,69.3,140.25,158.4,,140.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.55,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF METHADONE MECONIUM DAY,3120433,CDM,301,RC,80358,CPT,,,,,,outpatient,facility,,,165,69.3,20.02,165,,140.25,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,111.04,,,percent of total billed charges,,,139.42,,,percent of total billed charges,,,,,,,,,143.55,,,percent of total billed charges,,,143.55,,,percent of total billed charges,,,140.25,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,153.45,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,,,,,,,165,,,fee schedule,,,165,,,fee schedule,,,165,,,fee schedule,,,,,,,,,128.86,,,percent of total billed charges,,,150.15,,,percent of total billed charges,,,,,,,,,,,,,,,20.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF OPIATE MECONIUM DAY 1 PLUS,3120441,CDM,301,RC,80361,CPT,,,,,,inpatient,facility,,,70,29.4,59.5,67.2,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.9,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF OPIATE MECONIUM DAY 1 PLUS,3120441,CDM,301,RC,80361,CPT,,,,,,outpatient,facility,,,70,29.4,18.9,70,,59.5,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,47.11,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,,,,,,,60.9,,,percent of total billed charges,,,60.9,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,70,,,fee schedule,,,70,,,fee schedule,,,70,,,fee schedule,,,,,,,,,54.67,,,percent of total billed charges,,,63.7,,,percent of total billed charges,,,,,,,,,,,,,,,28.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE NUDT15 VAR COMMON NS,3120516,CDM,310,RC,81306,CPT,,,,,,inpatient,facility,,,875,367.5,743.75,840,,743.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,787.5,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE NUDT15 VAR COMMON NS,3120516,CDM,310,RC,81306,CPT,,,,,,outpatient,facility,,,875,367.5,236.25,875,,743.75,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,,602,,,percent of total billed charges,,,588.87,,,percent of total billed charges,,,739.38,,,percent of total billed charges,,,291.36,,,fee schedule,,,761.25,,,percent of total billed charges,,,761.25,,,percent of total billed charges,,,743.75,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,297.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",787.5,,,percent of total billed charges,,,291.36,,,fee schedule,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,422.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",393.34,,,fee schedule,,,875,,,fee schedule,,,875,,,fee schedule,,,875,,,fee schedule,,,291.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",683.38,,,percent of total billed charges,,,796.25,,,percent of total billed charges,,,291.36,,,fee schedule,,,291.36,,,fee schedule,,,,,,,,
LAB GENE SMN1 ANALYSIS DOSAGE DEL,3120524,CDM,310,RC,81329,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE SMN1 ANALYSIS DOSAGE DEL,3120524,CDM,310,RC,81329,CPT,,,,,,outpatient,facility,,,525,220.5,119.88,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,137,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,139.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,137,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,198.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",184.95,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,137,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,137,,,fee schedule,,,137,,,fee schedule,,,119.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC DET IA FLU REV T ANDPRB AMP 1 2,3120540,CDM,306,RC,87502,CPT,,,,,,inpatient,facility,,,288,120.96,244.8,276.48,,244.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.56,,,percent of total billed charges,,,,,,,,,259.2,,,percent of total billed charges,,,276.48,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,267.84,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC DET IA FLU REV T ANDPRB AMP 1 2,3120540,CDM,306,RC,87502,CPT,,,,,,outpatient,facility,,,288,120.96,77.76,276.48,,244.8,,,percent of total billed charges,,,77.76,,,percent of total billed charges,,,198.14,,,percent of total billed charges,,,193.82,,,percent of total billed charges,,,243.36,,,percent of total billed charges,,,95.8,,,fee schedule,,,250.56,,,percent of total billed charges,,,250.56,,,percent of total billed charges,,,244.8,,,percent of total billed charges,,,276.48,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,97.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",259.2,,,percent of total billed charges,,,95.8,,,fee schedule,,,267.84,,,percent of total billed charges,,,273.6,,,percent of total billed charges,,,138.91,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",129.33,,,fee schedule,,,85.07,,,fee schedule,,,85.07,,,fee schedule,,,83.37,,,fee schedule,,,95.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",224.93,,,percent of total billed charges,,,262.08,,,percent of total billed charges,,,95.8,,,fee schedule,,,95.8,,,fee schedule,,,101.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
POC DET AG IA STREP GROUP A IMM OPT,3120557,CDM,306,RC,87880,CPT,,,,,,inpatient,facility,,,50,21,42.5,48,,42.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,43.5,,,percent of total billed charges,,,,,,,,,45,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC DET AG IA STREP GROUP A IMM OPT,3120557,CDM,306,RC,87880,CPT,,,,,,outpatient,facility,,,50,21,13.5,48,,42.5,,,percent of total billed charges,,,13.5,,,percent of total billed charges,,,34.4,,,percent of total billed charges,,,33.65,,,percent of total billed charges,,,42.25,,,percent of total billed charges,,,16.53,,,fee schedule,,,43.5,,,percent of total billed charges,,,43.5,,,percent of total billed charges,,,42.5,,,percent of total billed charges,,,48,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,16.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45,,,percent of total billed charges,,,16.53,,,fee schedule,,,46.5,,,percent of total billed charges,,,47.5,,,percent of total billed charges,,,23.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",22.32,,,fee schedule,,,14.68,,,fee schedule,,,14.68,,,fee schedule,,,14.39,,,fee schedule,,,16.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",39.05,,,percent of total billed charges,,,45.5,,,percent of total billed charges,,,16.53,,,fee schedule,,,16.53,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HCV INFCT DIS CHRNC 6 ASSAYS,3120573,CDM,310,RC,81596,CPT,,,,,,inpatient,facility,,,217,91.14,184.45,208.32,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.79,,,percent of total billed charges,,,,,,,,,195.3,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HCV INFCT DIS CHRNC 6 ASSAYS,3120573,CDM,310,RC,81596,CPT,,,,,,outpatient,facility,,,217,91.14,58.59,217,,184.45,,,percent of total billed charges,,,58.59,,,percent of total billed charges,,,149.3,,,percent of total billed charges,,,146.04,,,percent of total billed charges,,,183.36,,,percent of total billed charges,,,72.19,,,fee schedule,,,188.79,,,percent of total billed charges,,,188.79,,,percent of total billed charges,,,184.45,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,73.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",195.3,,,percent of total billed charges,,,72.19,,,fee schedule,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,104.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.46,,,fee schedule,,,217,,,fee schedule,,,217,,,fee schedule,,,217,,,fee schedule,,,72.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",169.48,,,percent of total billed charges,,,197.47,,,percent of total billed charges,,,72.19,,,fee schedule,,,72.19,,,fee schedule,,,63.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB TEST GENETIC COND SEVERE INHRTD,3120581,CDM,310,RC,81443,CPT,,,,,,inpatient,facility,,,7346,3085.32,6244.1,7052.16,,6244.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6391.02,,,percent of total billed charges,,,,,,,,,6611.4,,,percent of total billed charges,,,7052.16,,,percent of total billed charges,,,6978.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6831.78,,,percent of total billed charges,,,6978.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TEST GENETIC COND SEVERE INHRTD,3120581,CDM,310,RC,81443,CPT,,,,,,outpatient,facility,,,7346,3085.32,1983.42,7346,,6244.1,,,percent of total billed charges,,,1983.42,,,percent of total billed charges,,,5054.05,,,percent of total billed charges,,,4943.86,,,percent of total billed charges,,,6207.37,,,percent of total billed charges,,,2448.56,,,fee schedule,,,6391.02,,,percent of total billed charges,,,6391.02,,,percent of total billed charges,,,6244.1,,,percent of total billed charges,,,7052.16,,,percent of total billed charges,,,6978.7,,,percent of total billed charges,,,2497.53,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6611.4,,,percent of total billed charges,,,2448.56,,,fee schedule,,,6831.78,,,percent of total billed charges,,,6978.7,,,percent of total billed charges,,,3550.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3305.56,,,fee schedule,,,7346,,,fee schedule,,,7346,,,fee schedule,,,7346,,,fee schedule,,,2448.56,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",5737.23,,,percent of total billed charges,,,6684.86,,,percent of total billed charges,,,2448.56,,,fee schedule,,,2448.56,,,fee schedule,,,2142.49,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB INFLIXIMAB,3120607,CDM,301,RC,80230,CPT,,,,,,inpatient,facility,,,266,111.72,226.1,255.36,,226.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,231.42,,,percent of total billed charges,,,,,,,,,239.4,,,percent of total billed charges,,,255.36,,,percent of total billed charges,,,252.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,247.38,,,percent of total billed charges,,,252.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB INFLIXIMAB,3120607,CDM,301,RC,80230,CPT,,,,,,outpatient,facility,,,266,111.72,33.57,255.36,,226.1,,,percent of total billed charges,,,71.82,,,percent of total billed charges,,,183.01,,,percent of total billed charges,,,179.02,,,percent of total billed charges,,,224.77,,,percent of total billed charges,,,38.57,,,fee schedule,,,231.42,,,percent of total billed charges,,,231.42,,,percent of total billed charges,,,226.1,,,percent of total billed charges,,,255.36,,,percent of total billed charges,,,252.7,,,percent of total billed charges,,,39.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",239.4,,,percent of total billed charges,,,38.57,,,fee schedule,,,247.38,,,percent of total billed charges,,,252.7,,,percent of total billed charges,,,55.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.07,,,fee schedule,,,34.25,,,fee schedule,,,34.25,,,fee schedule,,,33.57,,,fee schedule,,,38.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",207.75,,,percent of total billed charges,,,242.06,,,percent of total billed charges,,,38.57,,,fee schedule,,,38.57,,,fee schedule,,,,,,,,
LAB DIHYDROTESTOSTERONE,3120656,CDM,301,RC,82642,CPT,,,,,,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIHYDROTESTOSTERONE,3120656,CDM,301,RC,82642,CPT,,,,,,outpatient,facility,,,88,36.96,23.76,84.48,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,29.28,,,fee schedule,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,29.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",79.2,,,percent of total billed charges,,,29.28,,,fee schedule,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,42.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.53,,,fee schedule,,,26,,,fee schedule,,,26,,,fee schedule,,,25.48,,,fee schedule,,,29.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,29.28,,,fee schedule,,,29.28,,,fee schedule,,,28.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE MYD88 VAR L265P,3120664,CDM,310,RC,81305,CPT,,,,,,inpatient,facility,,,527,221.34,447.95,505.92,,447.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.49,,,percent of total billed charges,,,,,,,,,474.3,,,percent of total billed charges,,,505.92,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,490.11,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MYD88 VAR L265P,3120664,CDM,310,RC,81305,CPT,,,,,,outpatient,facility,,,527,221.34,142.29,527,,447.95,,,percent of total billed charges,,,142.29,,,percent of total billed charges,,,362.58,,,percent of total billed charges,,,354.67,,,percent of total billed charges,,,445.31,,,percent of total billed charges,,,175.4,,,fee schedule,,,458.49,,,percent of total billed charges,,,458.49,,,percent of total billed charges,,,447.95,,,percent of total billed charges,,,505.92,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,178.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",474.3,,,percent of total billed charges,,,175.4,,,fee schedule,,,490.11,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,254.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",236.79,,,fee schedule,,,527,,,fee schedule,,,527,,,fee schedule,,,527,,,fee schedule,,,175.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",411.59,,,percent of total billed charges,,,479.57,,,percent of total billed charges,,,175.4,,,fee schedule,,,175.4,,,fee schedule,,,,,,,,
LAB COMPLEMENT ACT FUNC NS,3120714,CDM,302,RC,86161,CPT,,,,,,inpatient,facility,,,185,77.7,157.25,177.6,,157.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.95,,,percent of total billed charges,,,,,,,,,166.5,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,172.05,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT ACT FUNC NS,3120714,CDM,302,RC,86161,CPT,,,,,,outpatient,facility,,,185,77.7,10.45,177.6,,157.25,,,percent of total billed charges,,,49.95,,,percent of total billed charges,,,127.28,,,percent of total billed charges,,,124.5,,,percent of total billed charges,,,156.32,,,percent of total billed charges,,,12,,,fee schedule,,,160.95,,,percent of total billed charges,,,160.95,,,percent of total billed charges,,,157.25,,,percent of total billed charges,,,177.6,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",166.5,,,percent of total billed charges,,,12,,,fee schedule,,,172.05,,,percent of total billed charges,,,175.75,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",144.48,,,percent of total billed charges,,,168.35,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB PARANEOPLASTIC CSF FL,3120755,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,200,84,170,192,,170,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174,,,percent of total billed charges,,,,,,,,,180,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB PARANEOPLASTIC CSF FL,3120755,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,200,84,10.49,192,,170,,,percent of total billed charges,,,54,,,percent of total billed charges,,,137.6,,,percent of total billed charges,,,134.6,,,percent of total billed charges,,,169,,,percent of total billed charges,,,12.05,,,fee schedule,,,174,,,percent of total billed charges,,,174,,,percent of total billed charges,,,170,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",180,,,percent of total billed charges,,,12.05,,,fee schedule,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",156.2,,,percent of total billed charges,,,182,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CSF3R MUTATION EXONS 14 AND17,3120763,CDM,310,RC,81479,CPT,,,,,,inpatient,facility,,,300,126,255,288,,255,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CSF3R MUTATION EXONS 14 AND17,3120763,CDM,310,RC,81479,CPT,,,,,,outpatient,facility,,,300,126,81,300,,255,,,percent of total billed charges,,,81,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,201.9,,,percent of total billed charges,,,253.5,,,percent of total billed charges,,,,,,,,,261,,,percent of total billed charges,,,261,,,percent of total billed charges,,,255,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,300,,,fee schedule,,,300,,,fee schedule,,,294,,,fee schedule,,,,,,,,,234.3,,,percent of total billed charges,,,273,,,percent of total billed charges,,,,,,,,,,,,,,,210,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA PNEUMOCYSTIS PCR PRB AMP,3120771,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA PNEUMOCYSTIS PCR PRB AMP,3120771,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA GI MULT PRB AMP 12 25TGT,3120821,CDM,306,RC,87507,CPT,,,,,,inpatient,facility,,,1251,525.42,1063.35,1200.96,,1063.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.37,,,percent of total billed charges,,,,,,,,,1125.9,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA GI MULT PRB AMP 12 25TGT,3120821,CDM,306,RC,87507,CPT,,,,,,outpatient,facility,,,1251,525.42,337.77,1200.96,,1063.35,,,percent of total billed charges,,,337.77,,,percent of total billed charges,,,860.69,,,percent of total billed charges,,,841.92,,,percent of total billed charges,,,1057.1,,,percent of total billed charges,,,416.78,,,fee schedule,,,1088.37,,,percent of total billed charges,,,1088.37,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,425.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1125.9,,,percent of total billed charges,,,416.78,,,fee schedule,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,604.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.65,,,fee schedule,,,370.1,,,fee schedule,,,370.1,,,fee schedule,,,362.7,,,fee schedule,,,416.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",977.03,,,percent of total billed charges,,,1138.41,,,percent of total billed charges,,,416.78,,,fee schedule,,,416.78,,,fee schedule,,,497.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NEURO CSF PRION PROT QUAL,3120839,CDM,310,RC,0035U,CPT,,,,,,inpatient,facility,,,1623,681.66,1379.55,1558.08,,1379.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1412.01,,,percent of total billed charges,,,,,,,,,1460.7,,,percent of total billed charges,,,1558.08,,,percent of total billed charges,,,1541.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1509.39,,,percent of total billed charges,,,1541.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NEURO CSF PRION PROT QUAL,3120839,CDM,310,RC,0035U,CPT,,,,,,outpatient,facility,,,1623,681.66,438.21,1623,,1379.55,,,percent of total billed charges,,,438.21,,,percent of total billed charges,,,1116.62,,,percent of total billed charges,,,1092.28,,,percent of total billed charges,,,1371.43,,,percent of total billed charges,,,540.99,,,fee schedule,,,1412.01,,,percent of total billed charges,,,1412.01,,,percent of total billed charges,,,1379.55,,,percent of total billed charges,,,1558.08,,,percent of total billed charges,,,1541.85,,,percent of total billed charges,,,551.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1460.7,,,percent of total billed charges,,,540.99,,,fee schedule,,,1509.39,,,percent of total billed charges,,,1541.85,,,percent of total billed charges,,,784.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",730.34,,,fee schedule,,,1623,,,fee schedule,,,1623,,,fee schedule,,,1623,,,fee schedule,,,540.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1267.56,,,percent of total billed charges,,,1476.93,,,percent of total billed charges,,,540.99,,,fee schedule,,,540.99,,,fee schedule,,,,,,,,
LAB SCR AB COPEPTIN FL,3120847,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,300,126,255,288,,255,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB COPEPTIN FL,3120847,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,300,126,10.49,288,,255,,,percent of total billed charges,,,81,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,201.9,,,percent of total billed charges,,,253.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,261,,,percent of total billed charges,,,261,,,percent of total billed charges,,,255,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",270,,,percent of total billed charges,,,12.05,,,fee schedule,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",234.3,,,percent of total billed charges,,,273,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHROMAT MS ORGANIC ACIDS,3120854,CDM,301,RC,82542,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS ORGANIC ACIDS,3120854,CDM,301,RC,82542,CPT,,,,,,outpatient,facility,,,153,64.26,14.06,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,24.09,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,24.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,24.09,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,34.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.52,,,fee schedule,,,21.39,,,fee schedule,,,21.39,,,fee schedule,,,20.96,,,fee schedule,,,24.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,24.09,,,fee schedule,,,24.09,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ CAMPY,3120888,CDM,306,RC,87449,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ CAMPY,3120888,CDM,306,RC,87449,CPT,,,,,,outpatient,facility,,,78,32.76,10.43,74.88,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,11.98,,,fee schedule,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",70.2,,,percent of total billed charges,,,11.98,,,fee schedule,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE CYP2C19 VAR COMMON,3120896,CDM,310,RC,81225,CPT,,,,,,inpatient,facility,,,875,367.5,743.75,840,,743.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,787.5,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CYP2C19 VAR COMMON,3120896,CDM,310,RC,81225,CPT,,,,,,outpatient,facility,,,875,367.5,236.25,875,,743.75,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,,602,,,percent of total billed charges,,,588.87,,,percent of total billed charges,,,739.38,,,percent of total billed charges,,,291.36,,,fee schedule,,,761.25,,,percent of total billed charges,,,761.25,,,percent of total billed charges,,,743.75,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,297.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",787.5,,,percent of total billed charges,,,291.36,,,fee schedule,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,422.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",393.34,,,fee schedule,,,875,,,fee schedule,,,875,,,fee schedule,,,875,,,fee schedule,,,291.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",683.38,,,percent of total billed charges,,,796.25,,,percent of total billed charges,,,291.36,,,fee schedule,,,291.36,,,fee schedule,,,,,,,,
LAB GENE CYP2D6 VAR COMMON,3120904,CDM,310,RC,81226,CPT,,,,,,inpatient,facility,,,1353,568.26,1150.05,1298.88,,1150.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1177.11,,,percent of total billed charges,,,,,,,,,1217.7,,,percent of total billed charges,,,1298.88,,,percent of total billed charges,,,1285.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1258.29,,,percent of total billed charges,,,1285.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CYP2D6 VAR COMMON,3120904,CDM,310,RC,81226,CPT,,,,,,outpatient,facility,,,1353,568.26,365.31,1353,,1150.05,,,percent of total billed charges,,,365.31,,,percent of total billed charges,,,930.86,,,percent of total billed charges,,,910.57,,,percent of total billed charges,,,1143.28,,,percent of total billed charges,,,450.91,,,fee schedule,,,1177.11,,,percent of total billed charges,,,1177.11,,,percent of total billed charges,,,1150.05,,,percent of total billed charges,,,1298.88,,,percent of total billed charges,,,1285.35,,,percent of total billed charges,,,459.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1217.7,,,percent of total billed charges,,,450.91,,,fee schedule,,,1258.29,,,percent of total billed charges,,,1285.35,,,percent of total billed charges,,,653.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",608.73,,,fee schedule,,,1353,,,fee schedule,,,1353,,,fee schedule,,,1353,,,fee schedule,,,450.91,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1056.69,,,percent of total billed charges,,,1231.23,,,percent of total billed charges,,,450.91,,,fee schedule,,,450.91,,,fee schedule,,,,,,,,
LAB GENE CYP2C9 VAR COMMON,3120912,CDM,310,RC,81227,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CYP2C9 VAR COMMON,3120912,CDM,310,RC,81227,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB GENE CYP3A4 VAR COMMON,3120920,CDM,310,RC,81230,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CYP3A4 VAR COMMON,3120920,CDM,310,RC,81230,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB GENE CYP3A5 VAR COMMON,3120938,CDM,310,RC,81231,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE CYP3A5 VAR COMMON,3120938,CDM,310,RC,81231,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB GENE DPYD VAR COMMON,3120946,CDM,310,RC,81232,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE DPYD VAR COMMON,3120946,CDM,310,RC,81232,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB GENE IFNL3,3120953,CDM,310,RC,81283,CPT,,,,,,inpatient,facility,,,221,92.82,187.85,212.16,,187.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.27,,,percent of total billed charges,,,,,,,,,198.9,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE IFNL3,3120953,CDM,310,RC,81283,CPT,,,,,,outpatient,facility,,,221,92.82,59.67,221,,187.85,,,percent of total billed charges,,,59.67,,,percent of total billed charges,,,152.05,,,percent of total billed charges,,,148.73,,,percent of total billed charges,,,186.75,,,percent of total billed charges,,,73.37,,,fee schedule,,,192.27,,,percent of total billed charges,,,192.27,,,percent of total billed charges,,,187.85,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,74.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",198.9,,,percent of total billed charges,,,73.37,,,fee schedule,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,106.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",99.05,,,fee schedule,,,221,,,fee schedule,,,221,,,fee schedule,,,221,,,fee schedule,,,73.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",172.6,,,percent of total billed charges,,,201.11,,,percent of total billed charges,,,73.37,,,fee schedule,,,73.37,,,fee schedule,,,,,,,,
LAB GENE SLCO1B1 VAR COMMON,3120979,CDM,310,RC,81328,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE SLCO1B1 VAR COMMON,3120979,CDM,310,RC,81328,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB GENE TPMT,3120987,CDM,310,RC,81335,CPT,,,,,,inpatient,facility,,,525,220.5,446.25,504,,446.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,456.75,,,percent of total billed charges,,,,,,,,,472.5,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TPMT,3120987,CDM,310,RC,81335,CPT,,,,,,outpatient,facility,,,525,220.5,141.75,525,,446.25,,,percent of total billed charges,,,141.75,,,percent of total billed charges,,,361.2,,,percent of total billed charges,,,353.32,,,percent of total billed charges,,,443.63,,,percent of total billed charges,,,174.81,,,fee schedule,,,456.75,,,percent of total billed charges,,,456.75,,,percent of total billed charges,,,446.25,,,percent of total billed charges,,,504,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,178.31,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",472.5,,,percent of total billed charges,,,174.81,,,fee schedule,,,488.25,,,percent of total billed charges,,,498.75,,,percent of total billed charges,,,253.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.99,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,525,,,fee schedule,,,174.81,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",410.02,,,percent of total billed charges,,,477.75,,,percent of total billed charges,,,174.81,,,fee schedule,,,174.81,,,fee schedule,,,,,,,,
LAB GENE UGT1A1 VAR COMMON,3120995,CDM,310,RC,81350,CPT,,,,,,inpatient,facility,,,702,294.84,596.7,673.92,,596.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,610.74,,,percent of total billed charges,,,,,,,,,631.8,,,percent of total billed charges,,,673.92,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,652.86,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE UGT1A1 VAR COMMON,3120995,CDM,310,RC,81350,CPT,,,,,,outpatient,facility,,,702,294.84,189.54,702,,596.7,,,percent of total billed charges,,,189.54,,,percent of total billed charges,,,482.98,,,percent of total billed charges,,,472.45,,,percent of total billed charges,,,593.19,,,percent of total billed charges,,,234,,,fee schedule,,,610.74,,,percent of total billed charges,,,610.74,,,percent of total billed charges,,,596.7,,,percent of total billed charges,,,673.92,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,238.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",631.8,,,percent of total billed charges,,,234,,,fee schedule,,,652.86,,,percent of total billed charges,,,666.9,,,percent of total billed charges,,,339.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",315.9,,,fee schedule,,,702,,,fee schedule,,,702,,,fee schedule,,,702,,,fee schedule,,,234,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",548.26,,,percent of total billed charges,,,638.82,,,percent of total billed charges,,,234,,,fee schedule,,,234,,,fee schedule,,,,,,,,
LAB GENE VKORC1 VAR COMMON,3121001,CDM,310,RC,81355,CPT,,,,,,inpatient,facility,,,265,111.3,225.25,254.4,,225.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,230.55,,,percent of total billed charges,,,,,,,,,238.5,,,percent of total billed charges,,,254.4,,,percent of total billed charges,,,251.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,246.45,,,percent of total billed charges,,,251.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE VKORC1 VAR COMMON,3121001,CDM,310,RC,81355,CPT,,,,,,outpatient,facility,,,265,111.3,71.55,265,,225.25,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,182.32,,,percent of total billed charges,,,178.34,,,percent of total billed charges,,,223.92,,,percent of total billed charges,,,88.2,,,fee schedule,,,230.55,,,percent of total billed charges,,,230.55,,,percent of total billed charges,,,225.25,,,percent of total billed charges,,,254.4,,,percent of total billed charges,,,251.75,,,percent of total billed charges,,,89.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",238.5,,,percent of total billed charges,,,88.2,,,fee schedule,,,246.45,,,percent of total billed charges,,,251.75,,,percent of total billed charges,,,127.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",119.07,,,fee schedule,,,265,,,fee schedule,,,265,,,fee schedule,,,265,,,fee schedule,,,88.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",206.97,,,percent of total billed charges,,,241.15,,,percent of total billed charges,,,88.2,,,fee schedule,,,88.2,,,fee schedule,,,,,,,,
LAB GENE PHARMOCOGENOMICS PANEL,3121019,CDM,310,RC,81479,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE PHARMOCOGENOMICS PANEL,3121019,CDM,310,RC,81479,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,51,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,,,,,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,51,,,fee schedule,,,51,,,fee schedule,,,49.98,,,fee schedule,,,,,,,,,39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,,,,,,,,,,,,,35.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AMMONIA STONE RISK,3121050,CDM,301,RC,82140,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AMMONIA STONE RISK,3121050,CDM,301,RC,82140,CPT,,,,,,outpatient,facility,,,115,48.3,12.68,110.4,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,14.57,,,fee schedule,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,14.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",103.5,,,percent of total billed charges,,,14.57,,,fee schedule,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,21.13,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.67,,,fee schedule,,,12.94,,,fee schedule,,,12.94,,,fee schedule,,,12.68,,,fee schedule,,,14.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,14.57,,,fee schedule,,,14.57,,,fee schedule,,,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CALCIUM STONE RISK,3121068,CDM,301,RC,82340,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CALCIUM STONE RISK,3121068,CDM,301,RC,82340,CPT,,,,,,outpatient,facility,,,77,32.34,5.24,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,6.03,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,6.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,6.03,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,8.74,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.14,,,fee schedule,,,5.35,,,fee schedule,,,5.35,,,fee schedule,,,5.24,,,fee schedule,,,6.03,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,6.03,,,fee schedule,,,6.03,,,fee schedule,,,7.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CITRATE STONE RISK,3121076,CDM,301,RC,82507,CPT,,,,,,inpatient,facility,,,174,73.08,147.9,167.04,,147.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,151.38,,,percent of total billed charges,,,,,,,,,156.6,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,161.82,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CITRATE STONE RISK,3121076,CDM,301,RC,82507,CPT,,,,,,outpatient,facility,,,174,73.08,24.2,167.04,,147.9,,,percent of total billed charges,,,46.98,,,percent of total billed charges,,,119.71,,,percent of total billed charges,,,117.1,,,percent of total billed charges,,,147.03,,,percent of total billed charges,,,27.8,,,fee schedule,,,151.38,,,percent of total billed charges,,,151.38,,,percent of total billed charges,,,147.9,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,28.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",156.6,,,percent of total billed charges,,,27.8,,,fee schedule,,,161.82,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,40.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",37.53,,,fee schedule,,,24.69,,,fee schedule,,,24.69,,,fee schedule,,,24.2,,,fee schedule,,,27.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",135.89,,,percent of total billed charges,,,158.34,,,percent of total billed charges,,,27.8,,,fee schedule,,,27.8,,,fee schedule,,,34.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CREATININE STONE RISK,3121084,CDM,301,RC,82570,CPT,,,,,,inpatient,facility,,,73,30.66,62.05,70.08,,62.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.51,,,percent of total billed charges,,,,,,,,,65.7,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CREATININE STONE RISK,3121084,CDM,301,RC,82570,CPT,,,,,,outpatient,facility,,,73,30.66,4.51,70.08,,62.05,,,percent of total billed charges,,,19.71,,,percent of total billed charges,,,50.22,,,percent of total billed charges,,,49.13,,,percent of total billed charges,,,61.68,,,percent of total billed charges,,,5.18,,,fee schedule,,,63.51,,,percent of total billed charges,,,63.51,,,percent of total billed charges,,,62.05,,,percent of total billed charges,,,70.08,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,5.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",65.7,,,percent of total billed charges,,,5.18,,,fee schedule,,,67.89,,,percent of total billed charges,,,69.35,,,percent of total billed charges,,,7.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.99,,,fee schedule,,,4.6,,,fee schedule,,,4.6,,,fee schedule,,,4.51,,,fee schedule,,,5.18,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.01,,,percent of total billed charges,,,66.43,,,percent of total billed charges,,,5.18,,,fee schedule,,,5.18,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB MAGNESIUM NS,3121092,CDM,301,RC,83735,CPT,,,,,,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB MAGNESIUM NS,3121092,CDM,301,RC,83735,CPT,,,,,,outpatient,facility,,,88,36.96,5.83,84.48,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,6.7,,,fee schedule,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,6.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",79.2,,,percent of total billed charges,,,6.7,,,fee schedule,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,9.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9.05,,,fee schedule,,,5.95,,,fee schedule,,,5.95,,,fee schedule,,,5.83,,,fee schedule,,,6.7,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,6.7,,,fee schedule,,,6.7,,,fee schedule,,,8.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB OXALATE STONE RISK,3121100,CDM,301,RC,83945,CPT,,,,,,inpatient,facility,,,108,45.36,91.8,103.68,,91.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.96,,,percent of total billed charges,,,,,,,,,97.2,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB OXALATE STONE RISK,3121100,CDM,301,RC,83945,CPT,,,,,,outpatient,facility,,,108,45.36,12.57,103.68,,91.8,,,percent of total billed charges,,,29.16,,,percent of total billed charges,,,74.3,,,percent of total billed charges,,,72.68,,,percent of total billed charges,,,91.26,,,percent of total billed charges,,,14.45,,,fee schedule,,,93.96,,,percent of total billed charges,,,93.96,,,percent of total billed charges,,,91.8,,,percent of total billed charges,,,103.68,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,14.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.2,,,percent of total billed charges,,,14.45,,,fee schedule,,,100.44,,,percent of total billed charges,,,102.6,,,percent of total billed charges,,,20.95,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.51,,,fee schedule,,,12.83,,,fee schedule,,,12.83,,,fee schedule,,,12.57,,,fee schedule,,,14.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",84.35,,,percent of total billed charges,,,98.28,,,percent of total billed charges,,,14.45,,,fee schedule,,,14.45,,,fee schedule,,,14.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PH STONE RISK,3121118,CDM,301,RC,83986,CPT,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PH STONE RISK,3121118,CDM,301,RC,83986,CPT,,,,,,outpatient,facility,,,66,27.72,1.43,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,3.58,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,3.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,3.58,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,5.19,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4.83,,,fee schedule,,,3.18,,,fee schedule,,,3.18,,,fee schedule,,,3.12,,,fee schedule,,,3.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,3.58,,,fee schedule,,,3.58,,,fee schedule,,,1.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PHOSPHORUS STONE RISK,3121126,CDM,301,RC,84105,CPT,,,,,,inpatient,facility,,,74,31.08,62.9,71.04,,62.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,64.38,,,percent of total billed charges,,,,,,,,,66.6,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PHOSPHORUS STONE RISK,3121126,CDM,301,RC,84105,CPT,,,,,,outpatient,facility,,,74,31.08,5.03,71.04,,62.9,,,percent of total billed charges,,,19.98,,,percent of total billed charges,,,50.91,,,percent of total billed charges,,,49.8,,,percent of total billed charges,,,62.53,,,percent of total billed charges,,,5.78,,,fee schedule,,,64.38,,,percent of total billed charges,,,64.38,,,percent of total billed charges,,,62.9,,,percent of total billed charges,,,71.04,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,5.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",66.6,,,percent of total billed charges,,,5.78,,,fee schedule,,,68.82,,,percent of total billed charges,,,70.3,,,percent of total billed charges,,,8.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.8,,,fee schedule,,,5.13,,,fee schedule,,,5.13,,,fee schedule,,,5.03,,,fee schedule,,,5.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",57.79,,,percent of total billed charges,,,67.34,,,percent of total billed charges,,,5.78,,,fee schedule,,,5.78,,,fee schedule,,,6.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB POTASSIUM STONE RISK,3121134,CDM,301,RC,84133,CPT,,,,,,inpatient,facility,,,70,29.4,59.5,67.2,,59.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,60.9,,,percent of total billed charges,,,,,,,,,63,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB POTASSIUM STONE RISK,3121134,CDM,301,RC,84133,CPT,,,,,,outpatient,facility,,,70,29.4,4.12,67.2,,59.5,,,percent of total billed charges,,,18.9,,,percent of total billed charges,,,48.16,,,percent of total billed charges,,,47.11,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,4.73,,,fee schedule,,,60.9,,,percent of total billed charges,,,60.9,,,percent of total billed charges,,,59.5,,,percent of total billed charges,,,67.2,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,4.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63,,,percent of total billed charges,,,4.73,,,fee schedule,,,65.1,,,percent of total billed charges,,,66.5,,,percent of total billed charges,,,6.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.39,,,fee schedule,,,4.2,,,fee schedule,,,4.2,,,fee schedule,,,4.12,,,fee schedule,,,4.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",54.67,,,percent of total billed charges,,,63.7,,,percent of total billed charges,,,4.73,,,fee schedule,,,4.73,,,fee schedule,,,5.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SODIUM STONE RISK,3121142,CDM,301,RC,84300,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SODIUM STONE RISK,3121142,CDM,301,RC,84300,CPT,,,,,,outpatient,facility,,,72,30.24,4.4,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,5.06,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,5.16,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,5.06,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,7.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.83,,,fee schedule,,,4.49,,,fee schedule,,,4.49,,,fee schedule,,,4.4,,,fee schedule,,,5.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,5.06,,,fee schedule,,,5.06,,,fee schedule,,,5.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SULFATE STONE RISK,3121159,CDM,301,RC,84392,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SULFATE STONE RISK,3121159,CDM,301,RC,84392,CPT,,,,,,outpatient,facility,,,72,30.24,4.78,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,5.49,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,5.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,5.49,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,7.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7.41,,,fee schedule,,,4.88,,,fee schedule,,,4.88,,,fee schedule,,,4.78,,,fee schedule,,,5.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,5.49,,,fee schedule,,,5.49,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB URIC ACID STONE RISK,3121167,CDM,301,RC,84560,CPT,,,,,,inpatient,facility,,,72,30.24,61.2,69.12,,61.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,62.64,,,percent of total billed charges,,,,,,,,,64.8,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB URIC ACID STONE RISK,3121167,CDM,301,RC,84560,CPT,,,,,,outpatient,facility,,,72,30.24,4.42,69.12,,61.2,,,percent of total billed charges,,,19.44,,,percent of total billed charges,,,49.54,,,percent of total billed charges,,,48.46,,,percent of total billed charges,,,60.84,,,percent of total billed charges,,,5.08,,,fee schedule,,,62.64,,,percent of total billed charges,,,62.64,,,percent of total billed charges,,,61.2,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,5.18,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",64.8,,,percent of total billed charges,,,5.08,,,fee schedule,,,66.96,,,percent of total billed charges,,,68.4,,,percent of total billed charges,,,7.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.86,,,fee schedule,,,4.51,,,fee schedule,,,4.51,,,fee schedule,,,4.42,,,fee schedule,,,5.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",56.23,,,percent of total billed charges,,,65.52,,,percent of total billed charges,,,5.08,,,fee schedule,,,5.08,,,fee schedule,,,5.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB HMGCR IGG,3121183,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,315,132.3,267.75,302.4,,267.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.05,,,percent of total billed charges,,,,,,,,,283.5,,,percent of total billed charges,,,302.4,,,percent of total billed charges,,,299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,292.95,,,percent of total billed charges,,,299.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB HMGCR IGG,3121183,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,315,132.3,15.03,302.4,,267.75,,,percent of total billed charges,,,85.05,,,percent of total billed charges,,,216.72,,,percent of total billed charges,,,211.99,,,percent of total billed charges,,,266.18,,,percent of total billed charges,,,17.27,,,fee schedule,,,274.05,,,percent of total billed charges,,,274.05,,,percent of total billed charges,,,267.75,,,percent of total billed charges,,,302.4,,,percent of total billed charges,,,299.25,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",283.5,,,percent of total billed charges,,,17.27,,,fee schedule,,,292.95,,,percent of total billed charges,,,299.25,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",246.01,,,percent of total billed charges,,,286.65,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIVER DISEASE 10 ASSAYS,3121209,CDM,300,RC,0003M,CPT,,,,,,inpatient,facility,,,1511,634.62,1284.35,1450.56,,1284.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1314.57,,,percent of total billed charges,,,,,,,,,1359.9,,,percent of total billed charges,,,1450.56,,,percent of total billed charges,,,1435.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1405.23,,,percent of total billed charges,,,1435.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIVER DISEASE 10 ASSAYS,3121209,CDM,300,RC,0003M,CPT,,,,,,outpatient,facility,,,1511,634.62,407.97,1511,,1284.35,,,percent of total billed charges,,,407.97,,,percent of total billed charges,,,1039.57,,,percent of total billed charges,,,1016.9,,,percent of total billed charges,,,1276.8,,,percent of total billed charges,,,503.4,,,fee schedule,,,1314.57,,,percent of total billed charges,,,1314.57,,,percent of total billed charges,,,1284.35,,,percent of total billed charges,,,1450.56,,,percent of total billed charges,,,1435.45,,,percent of total billed charges,,,513.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1359.9,,,percent of total billed charges,,,503.4,,,fee schedule,,,1405.23,,,percent of total billed charges,,,1435.45,,,percent of total billed charges,,,729.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",679.59,,,fee schedule,,,1511,,,fee schedule,,,1511,,,fee schedule,,,1511,,,fee schedule,,,503.4,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1180.09,,,percent of total billed charges,,,1375.01,,,percent of total billed charges,,,503.4,,,fee schedule,,,503.4,,,fee schedule,,,,,,,,
LAB DET IA IGM PRB AMP,3121225,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA IGM PRB AMP,3121225,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM OPTICAL NS,3121274,CDM,306,RC,87899,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM OPTICAL NS,3121274,CDM,306,RC,87899,CPT,,,,,,outpatient,facility,,,75,31.5,13.98,72,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,16.07,,,fee schedule,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,16.39,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",67.5,,,percent of total billed charges,,,16.07,,,fee schedule,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,23.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",21.69,,,fee schedule,,,14.27,,,fee schedule,,,14.27,,,fee schedule,,,13.98,,,fee schedule,,,16.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,16.07,,,fee schedule,,,16.07,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HLA CLASS II AB HIGH DEF QL NS,3121290,CDM,302,RC,86833,CPT,,,,,,inpatient,facility,,,978,410.76,831.3,938.88,,831.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,850.86,,,percent of total billed charges,,,,,,,,,880.2,,,percent of total billed charges,,,938.88,,,percent of total billed charges,,,929.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,909.54,,,percent of total billed charges,,,929.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HLA CLASS II AB HIGH DEF QL NS,3121290,CDM,302,RC,86833,CPT,,,,,,outpatient,facility,,,978,410.76,139.13,938.88,,831.3,,,percent of total billed charges,,,264.06,,,percent of total billed charges,,,672.86,,,percent of total billed charges,,,658.19,,,percent of total billed charges,,,826.41,,,percent of total billed charges,,,325.8,,,fee schedule,,,850.86,,,percent of total billed charges,,,850.86,,,percent of total billed charges,,,831.3,,,percent of total billed charges,,,938.88,,,percent of total billed charges,,,929.1,,,percent of total billed charges,,,332.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",880.2,,,percent of total billed charges,,,325.8,,,fee schedule,,,909.54,,,percent of total billed charges,,,929.1,,,percent of total billed charges,,,472.41,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",439.83,,,fee schedule,,,289.31,,,fee schedule,,,289.31,,,fee schedule,,,283.52,,,fee schedule,,,325.8,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",763.82,,,percent of total billed charges,,,889.98,,,percent of total billed charges,,,325.8,,,fee schedule,,,325.8,,,fee schedule,,,139.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE TYPING HLA 1 LR LOCUS NS,3121308,CDM,310,RC,81373,CPT,,,,,,inpatient,facility,,,383,160.86,325.55,367.68,,325.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,333.21,,,percent of total billed charges,,,,,,,,,344.7,,,percent of total billed charges,,,367.68,,,percent of total billed charges,,,363.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,356.19,,,percent of total billed charges,,,363.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 LR LOCUS NS,3121308,CDM,310,RC,81373,CPT,,,,,,outpatient,facility,,,383,160.86,103.41,367.68,,325.55,,,percent of total billed charges,,,103.41,,,percent of total billed charges,,,263.5,,,percent of total billed charges,,,257.76,,,percent of total billed charges,,,323.63,,,percent of total billed charges,,,127.43,,,fee schedule,,,333.21,,,percent of total billed charges,,,333.21,,,percent of total billed charges,,,325.55,,,percent of total billed charges,,,367.68,,,percent of total billed charges,,,363.85,,,percent of total billed charges,,,129.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",344.7,,,percent of total billed charges,,,127.43,,,fee schedule,,,356.19,,,percent of total billed charges,,,363.85,,,percent of total billed charges,,,184.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",172.03,,,fee schedule,,,113.16,,,fee schedule,,,113.16,,,fee schedule,,,110.9,,,fee schedule,,,127.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",299.12,,,percent of total billed charges,,,348.53,,,percent of total billed charges,,,127.43,,,fee schedule,,,127.43,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 2 LR LOCUS NS,3121316,CDM,310,RC,81376,CPT,,,,,,inpatient,facility,,,367,154.14,311.95,352.32,,311.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,319.29,,,percent of total billed charges,,,,,,,,,330.3,,,percent of total billed charges,,,352.32,,,percent of total billed charges,,,348.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,341.31,,,percent of total billed charges,,,348.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 2 LR LOCUS NS,3121316,CDM,310,RC,81376,CPT,,,,,,outpatient,facility,,,367,154.14,99.09,352.32,,311.95,,,percent of total billed charges,,,99.09,,,percent of total billed charges,,,252.5,,,percent of total billed charges,,,246.99,,,percent of total billed charges,,,310.12,,,percent of total billed charges,,,122.22,,,fee schedule,,,319.29,,,percent of total billed charges,,,319.29,,,percent of total billed charges,,,311.95,,,percent of total billed charges,,,352.32,,,percent of total billed charges,,,348.65,,,percent of total billed charges,,,124.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",330.3,,,percent of total billed charges,,,122.22,,,fee schedule,,,341.31,,,percent of total billed charges,,,348.65,,,percent of total billed charges,,,177.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",165,,,fee schedule,,,108.53,,,fee schedule,,,108.53,,,fee schedule,,,106.36,,,fee schedule,,,122.22,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",286.63,,,percent of total billed charges,,,333.97,,,percent of total billed charges,,,122.22,,,fee schedule,,,122.22,,,fee schedule,,,,,,,,
LAB HLA CLASS I AB HIGH DEF QL NS,3121332,CDM,302,RC,86832,CPT,,,,,,inpatient,facility,,,972,408.24,826.2,933.12,,826.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,845.64,,,percent of total billed charges,,,,,,,,,874.8,,,percent of total billed charges,,,933.12,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,903.96,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HLA CLASS I AB HIGH DEF QL NS,3121332,CDM,302,RC,86832,CPT,,,,,,outpatient,facility,,,972,408.24,153.04,933.12,,826.2,,,percent of total billed charges,,,262.44,,,percent of total billed charges,,,668.74,,,percent of total billed charges,,,654.16,,,percent of total billed charges,,,821.34,,,percent of total billed charges,,,323.75,,,fee schedule,,,845.64,,,percent of total billed charges,,,845.64,,,percent of total billed charges,,,826.2,,,percent of total billed charges,,,933.12,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,330.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",874.8,,,percent of total billed charges,,,323.75,,,fee schedule,,,903.96,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,469.44,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",437.06,,,fee schedule,,,287.49,,,fee schedule,,,287.49,,,fee schedule,,,281.74,,,fee schedule,,,323.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",759.13,,,percent of total billed charges,,,884.52,,,percent of total billed charges,,,323.75,,,fee schedule,,,323.75,,,fee schedule,,,153.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE TYPING HLA 1 AND2 HR NS,3121340,CDM,310,RC,81378,CPT,,,,,,inpatient,facility,,,1037,435.54,881.45,995.52,,881.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,902.19,,,percent of total billed charges,,,,,,,,,933.3,,,percent of total billed charges,,,995.52,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,964.41,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 AND2 HR NS,3121340,CDM,310,RC,81378,CPT,,,,,,outpatient,facility,,,1037,435.54,279.99,995.52,,881.45,,,percent of total billed charges,,,279.99,,,percent of total billed charges,,,713.46,,,percent of total billed charges,,,697.9,,,percent of total billed charges,,,876.26,,,percent of total billed charges,,,345.57,,,fee schedule,,,902.19,,,percent of total billed charges,,,902.19,,,percent of total billed charges,,,881.45,,,percent of total billed charges,,,995.52,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,352.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",933.3,,,percent of total billed charges,,,345.57,,,fee schedule,,,964.41,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,501.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",466.52,,,fee schedule,,,306.87,,,fee schedule,,,306.87,,,fee schedule,,,300.73,,,fee schedule,,,345.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",809.9,,,percent of total billed charges,,,943.67,,,percent of total billed charges,,,345.57,,,fee schedule,,,345.57,,,fee schedule,,,,,,,,
LAB IMM NEUTRPHL GEL ASSC LIPOCALIN,3121357,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,52,21.84,44.2,49.92,,44.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,45.24,,,percent of total billed charges,,,,,,,,,46.8,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM NEUTRPHL GEL ASSC LIPOCALIN,3121357,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,52,21.84,14.04,49.92,,44.2,,,percent of total billed charges,,,14.04,,,percent of total billed charges,,,35.78,,,percent of total billed charges,,,35,,,percent of total billed charges,,,43.94,,,percent of total billed charges,,,17.27,,,fee schedule,,,45.24,,,percent of total billed charges,,,45.24,,,percent of total billed charges,,,44.2,,,percent of total billed charges,,,49.92,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.8,,,percent of total billed charges,,,17.27,,,fee schedule,,,48.36,,,percent of total billed charges,,,49.4,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",40.61,,,percent of total billed charges,,,47.32,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HLA CLASS I ANDII AB QL NS,3121365,CDM,302,RC,86828,CPT,,,,,,inpatient,facility,,,330,138.6,280.5,316.8,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.1,,,percent of total billed charges,,,,,,,,,297,,,percent of total billed charges,,,316.8,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,306.9,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HLA CLASS I ANDII AB QL NS,3121365,CDM,302,RC,86828,CPT,,,,,,outpatient,facility,,,330,138.6,47.74,316.8,,280.5,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,227.04,,,percent of total billed charges,,,222.09,,,percent of total billed charges,,,278.85,,,percent of total billed charges,,,64.19,,,fee schedule,,,287.1,,,percent of total billed charges,,,287.1,,,percent of total billed charges,,,280.5,,,percent of total billed charges,,,316.8,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,65.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",297,,,percent of total billed charges,,,64.19,,,fee schedule,,,306.9,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,93.08,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",86.66,,,fee schedule,,,57,,,fee schedule,,,57,,,fee schedule,,,55.86,,,fee schedule,,,64.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",257.73,,,percent of total billed charges,,,300.3,,,percent of total billed charges,,,64.19,,,fee schedule,,,64.19,,,fee schedule,,,47.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ADALIMUMAB,3121456,CDM,301,RC,80145,CPT,,,,,,inpatient,facility,,,300,126,255,288,,255,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ADALIMUMAB,3121456,CDM,301,RC,80145,CPT,,,,,,outpatient,facility,,,300,126,33.57,288,,255,,,percent of total billed charges,,,81,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,201.9,,,percent of total billed charges,,,253.5,,,percent of total billed charges,,,38.57,,,fee schedule,,,261,,,percent of total billed charges,,,261,,,percent of total billed charges,,,255,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,39.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",270,,,percent of total billed charges,,,38.57,,,fee schedule,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,55.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.07,,,fee schedule,,,34.25,,,fee schedule,,,34.25,,,fee schedule,,,33.57,,,fee schedule,,,38.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",234.3,,,percent of total billed charges,,,273,,,percent of total billed charges,,,38.57,,,fee schedule,,,38.57,,,fee schedule,,,,,,,,
LAB LACOSAMIDE,3121464,CDM,301,RC,80235,CPT,,,,,,inpatient,facility,,,82,34.44,69.7,78.72,,69.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.34,,,percent of total billed charges,,,,,,,,,73.8,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LACOSAMIDE,3121464,CDM,301,RC,80235,CPT,,,,,,outpatient,facility,,,82,34.44,22.14,78.72,,69.7,,,percent of total billed charges,,,22.14,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,55.19,,,percent of total billed charges,,,69.29,,,percent of total billed charges,,,27.11,,,fee schedule,,,71.34,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,69.7,,,percent of total billed charges,,,78.72,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,27.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",73.8,,,percent of total billed charges,,,27.11,,,fee schedule,,,76.26,,,percent of total billed charges,,,77.9,,,percent of total billed charges,,,39.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",36.6,,,fee schedule,,,24.07,,,fee schedule,,,24.07,,,fee schedule,,,23.59,,,fee schedule,,,27.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",64.04,,,percent of total billed charges,,,74.62,,,percent of total billed charges,,,27.11,,,fee schedule,,,27.11,,,fee schedule,,,,,,,,
LAB GENE HTT DET ALLELES ABNORMAL,3121480,CDM,310,RC,81271,CPT,,,,,,inpatient,facility,,,411,172.62,349.35,394.56,,349.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,357.57,,,percent of total billed charges,,,,,,,,,369.9,,,percent of total billed charges,,,394.56,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,382.23,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE HTT DET ALLELES ABNORMAL,3121480,CDM,310,RC,81271,CPT,,,,,,outpatient,facility,,,411,172.62,110.97,411,,349.35,,,percent of total billed charges,,,110.97,,,percent of total billed charges,,,282.77,,,percent of total billed charges,,,276.6,,,percent of total billed charges,,,347.3,,,percent of total billed charges,,,137,,,fee schedule,,,357.57,,,percent of total billed charges,,,357.57,,,percent of total billed charges,,,349.35,,,percent of total billed charges,,,394.56,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,139.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",369.9,,,percent of total billed charges,,,137,,,fee schedule,,,382.23,,,percent of total billed charges,,,390.45,,,percent of total billed charges,,,198.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",184.95,,,fee schedule,,,411,,,fee schedule,,,411,,,fee schedule,,,411,,,fee schedule,,,137,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",320.99,,,percent of total billed charges,,,374.01,,,percent of total billed charges,,,137,,,fee schedule,,,137,,,fee schedule,,,,,,,,
LAB FRAGILITY OSMOTIC RBC INCUB NS,3121514,CDM,305,RC,85557,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB FRAGILITY OSMOTIC RBC INCUB NS,3121514,CDM,305,RC,85557,CPT,,,,,,outpatient,facility,,,187,78.54,11.62,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,13.36,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,13.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,13.36,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,19.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18.04,,,fee schedule,,,11.86,,,fee schedule,,,11.86,,,fee schedule,,,11.62,,,fee schedule,,,13.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,13.36,,,fee schedule,,,13.36,,,fee schedule,,,16.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ONC BIOCHEMICAL PROT 2 SERUM,3121530,CDM,310,RC,81500,CPT,,,,,,inpatient,facility,,,782,328.44,664.7,750.72,,664.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,680.34,,,percent of total billed charges,,,,,,,,,703.8,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,742.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,727.26,,,percent of total billed charges,,,742.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ONC BIOCHEMICAL PROT 2 SERUM,3121530,CDM,310,RC,81500,CPT,,,,,,outpatient,facility,,,782,328.44,211.14,782,,664.7,,,percent of total billed charges,,,211.14,,,percent of total billed charges,,,538.02,,,percent of total billed charges,,,526.29,,,percent of total billed charges,,,660.79,,,percent of total billed charges,,,260.5,,,fee schedule,,,680.34,,,percent of total billed charges,,,680.34,,,percent of total billed charges,,,664.7,,,percent of total billed charges,,,750.72,,,percent of total billed charges,,,742.9,,,percent of total billed charges,,,265.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",703.8,,,percent of total billed charges,,,260.5,,,fee schedule,,,727.26,,,percent of total billed charges,,,742.9,,,percent of total billed charges,,,377.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",351.68,,,fee schedule,,,782,,,fee schedule,,,782,,,fee schedule,,,782,,,fee schedule,,,260.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",610.74,,,percent of total billed charges,,,711.62,,,percent of total billed charges,,,260.5,,,fee schedule,,,260.5,,,fee schedule,,,,,,,,
LAB GENE TYPING HLA 2 HR LOCUS NS,3121563,CDM,310,RC,81382,CPT,,,,,,inpatient,facility,,,372,156.24,316.2,357.12,,316.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,323.64,,,percent of total billed charges,,,,,,,,,334.8,,,percent of total billed charges,,,357.12,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,345.96,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 2 HR LOCUS NS,3121563,CDM,310,RC,81382,CPT,,,,,,outpatient,facility,,,372,156.24,100.44,357.12,,316.2,,,percent of total billed charges,,,100.44,,,percent of total billed charges,,,255.94,,,percent of total billed charges,,,250.36,,,percent of total billed charges,,,314.34,,,percent of total billed charges,,,123.68,,,fee schedule,,,323.64,,,percent of total billed charges,,,323.64,,,percent of total billed charges,,,316.2,,,percent of total billed charges,,,357.12,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,126.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",334.8,,,percent of total billed charges,,,123.68,,,fee schedule,,,345.96,,,percent of total billed charges,,,353.4,,,percent of total billed charges,,,179.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",166.97,,,fee schedule,,,109.83,,,fee schedule,,,109.83,,,fee schedule,,,107.63,,,fee schedule,,,123.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",290.53,,,percent of total billed charges,,,338.52,,,percent of total billed charges,,,123.68,,,fee schedule,,,123.68,,,fee schedule,,,108.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF BARB PHENOBARB DAY NS,3121571,CDM,301,RC,80345,CPT,,,,,,inpatient,facility,,,158,66.36,134.3,151.68,,134.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,137.46,,,percent of total billed charges,,,,,,,,,142.2,,,percent of total billed charges,,,151.68,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,146.94,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BARB PHENOBARB DAY NS,3121571,CDM,301,RC,80345,CPT,,,,,,outpatient,facility,,,158,66.36,14.05,158,,134.3,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,108.7,,,percent of total billed charges,,,106.33,,,percent of total billed charges,,,133.51,,,percent of total billed charges,,,,,,,,,137.46,,,percent of total billed charges,,,137.46,,,percent of total billed charges,,,134.3,,,percent of total billed charges,,,151.68,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,142.2,,,percent of total billed charges,,,,,,,,,146.94,,,percent of total billed charges,,,150.1,,,percent of total billed charges,,,,,,,,,,,,,,,158,,,fee schedule,,,158,,,fee schedule,,,158,,,fee schedule,,,,,,,,,123.4,,,percent of total billed charges,,,143.78,,,percent of total billed charges,,,,,,,,,,,,,,,14.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS 21 HYDROXYLASE QL,3121589,CDM,300,RC,83516,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS 21 HYDROXYLASE QL,3121589,CDM,300,RC,83516,CPT,,,,,,outpatient,facility,,,114,47.88,10.04,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,11.53,,,fee schedule,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.6,,,percent of total billed charges,,,11.53,,,fee schedule,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE FLT3 VAR ITD QN,3121597,CDM,310,RC,0046U,CPT,,,,,,inpatient,facility,,,1800,756,1530,1728,,1530,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1566,,,percent of total billed charges,,,,,,,,,1620,,,percent of total billed charges,,,1728,,,percent of total billed charges,,,1710,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1674,,,percent of total billed charges,,,1710,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE FLT3 VAR ITD QN,3121597,CDM,310,RC,0046U,CPT,,,,,,outpatient,facility,,,1800,756,407.43,1800,,1530,,,percent of total billed charges,,,486,,,percent of total billed charges,,,1238.4,,,percent of total billed charges,,,1211.4,,,percent of total billed charges,,,1521,,,percent of total billed charges,,,407.43,,,fee schedule,,,1566,,,percent of total billed charges,,,1566,,,percent of total billed charges,,,1530,,,percent of total billed charges,,,1728,,,percent of total billed charges,,,1710,,,percent of total billed charges,,,415.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1620,,,percent of total billed charges,,,407.43,,,fee schedule,,,1674,,,percent of total billed charges,,,1710,,,percent of total billed charges,,,590.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",550.03,,,fee schedule,,,1800,,,fee schedule,,,1800,,,fee schedule,,,1800,,,fee schedule,,,407.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1405.8,,,percent of total billed charges,,,1638,,,percent of total billed charges,,,407.43,,,fee schedule,,,407.43,,,fee schedule,,,,,,,,
LAB DET IA MYCOPLAS GEN PRB AMP,3121621,CDM,306,RC,87563,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MYCOPLAS GEN PRB AMP,3121621,CDM,306,RC,87563,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,,,,,,
LAB SCR AB ENCEPHALITIS FL,3121647,CDM,302,RC,86255,CPT,,,,,,inpatient,facility,,,98,41.16,83.3,94.08,,83.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,85.26,,,percent of total billed charges,,,,,,,,,88.2,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB ENCEPHALITIS FL,3121647,CDM,302,RC,86255,CPT,,,,,,outpatient,facility,,,98,41.16,10.49,94.08,,83.3,,,percent of total billed charges,,,26.46,,,percent of total billed charges,,,67.42,,,percent of total billed charges,,,65.95,,,percent of total billed charges,,,82.81,,,percent of total billed charges,,,12.05,,,fee schedule,,,85.26,,,percent of total billed charges,,,85.26,,,percent of total billed charges,,,83.3,,,percent of total billed charges,,,94.08,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.2,,,percent of total billed charges,,,12.05,,,fee schedule,,,91.14,,,percent of total billed charges,,,93.1,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",76.54,,,percent of total billed charges,,,89.18,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,14.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NPM1 GENE ANALYSIS QUAN,3121654,CDM,310,RC,0049U,CPT,,,,,,inpatient,facility,,,1750,735,1487.5,1680,,1487.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1522.5,,,percent of total billed charges,,,,,,,,,1575,,,percent of total billed charges,,,1680,,,percent of total billed charges,,,1662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1627.5,,,percent of total billed charges,,,1662.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NPM1 GENE ANALYSIS QUAN,3121654,CDM,310,RC,0049U,CPT,,,,,,outpatient,facility,,,1750,735,407.43,1750,,1487.5,,,percent of total billed charges,,,472.5,,,percent of total billed charges,,,1204,,,percent of total billed charges,,,1177.75,,,percent of total billed charges,,,1478.75,,,percent of total billed charges,,,407.43,,,fee schedule,,,1522.5,,,percent of total billed charges,,,1522.5,,,percent of total billed charges,,,1487.5,,,percent of total billed charges,,,1680,,,percent of total billed charges,,,1662.5,,,percent of total billed charges,,,415.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1575,,,percent of total billed charges,,,407.43,,,fee schedule,,,1627.5,,,percent of total billed charges,,,1662.5,,,percent of total billed charges,,,590.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",550.03,,,fee schedule,,,1750,,,fee schedule,,,1750,,,fee schedule,,,1750,,,fee schedule,,,407.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1366.75,,,percent of total billed charges,,,1592.5,,,percent of total billed charges,,,407.43,,,fee schedule,,,407.43,,,fee schedule,,,,,,,,
LAB NGS MI PROFILE,3121688,CDM,310,RC,81479,CPT,,,,,,inpatient,facility,,,2970,1247.4,2524.5,2851.2,,2524.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2583.9,,,percent of total billed charges,,,,,,,,,2673,,,percent of total billed charges,,,2851.2,,,percent of total billed charges,,,2821.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2762.1,,,percent of total billed charges,,,2821.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NGS MI PROFILE,3121688,CDM,310,RC,81479,CPT,,,,,,outpatient,facility,,,2970,1247.4,801.9,2970,,2524.5,,,percent of total billed charges,,,801.9,,,percent of total billed charges,,,2043.36,,,percent of total billed charges,,,1998.81,,,percent of total billed charges,,,2509.65,,,percent of total billed charges,,,,,,,,,2583.9,,,percent of total billed charges,,,2583.9,,,percent of total billed charges,,,2524.5,,,percent of total billed charges,,,2851.2,,,percent of total billed charges,,,2821.5,,,percent of total billed charges,,,,,,,,,2673,,,percent of total billed charges,,,,,,,,,2762.1,,,percent of total billed charges,,,2821.5,,,percent of total billed charges,,,,,,,,,,,,,,,2970,,,fee schedule,,,2970,,,fee schedule,,,2910.6,,,fee schedule,,,,,,,,,2319.57,,,percent of total billed charges,,,2702.7,,,percent of total billed charges,,,,,,,,,,,,,,,2079,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB LIPOPROTEIN CHOLESTEROL LDL SD,3121696,CDM,301,RC,83722,CPT,,,,,,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB LIPOPROTEIN CHOLESTEROL LDL SD,3121696,CDM,301,RC,83722,CPT,,,,,,outpatient,facility,,,103,43.26,27.81,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,34.19,,,fee schedule,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,34.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",92.7,,,percent of total billed charges,,,34.19,,,fee schedule,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,49.58,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",46.16,,,fee schedule,,,30.36,,,fee schedule,,,30.36,,,fee schedule,,,29.75,,,fee schedule,,,34.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,34.19,,,fee schedule,,,34.19,,,fee schedule,,,30.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA RESP NA 18 VIRAL AND2 BACT,3121746,CDM,310,RC,0115U,CPT,,,,,,inpatient,facility,,,827,347.34,702.95,793.92,,702.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.49,,,percent of total billed charges,,,,,,,,,744.3,,,percent of total billed charges,,,793.92,,,percent of total billed charges,,,785.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,769.11,,,percent of total billed charges,,,785.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA RESP NA 18 VIRAL AND2 BACT,3121746,CDM,310,RC,0115U,CPT,,,,,,outpatient,facility,,,827,347.34,223.29,827,,702.95,,,percent of total billed charges,,,223.29,,,percent of total billed charges,,,568.98,,,percent of total billed charges,,,556.57,,,percent of total billed charges,,,698.81,,,percent of total billed charges,,,275.35,,,fee schedule,,,719.49,,,percent of total billed charges,,,719.49,,,percent of total billed charges,,,702.95,,,percent of total billed charges,,,793.92,,,percent of total billed charges,,,785.65,,,percent of total billed charges,,,280.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.3,,,percent of total billed charges,,,275.35,,,fee schedule,,,769.11,,,percent of total billed charges,,,785.65,,,percent of total billed charges,,,399.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",371.72,,,fee schedule,,,827,,,fee schedule,,,827,,,fee schedule,,,827,,,fee schedule,,,275.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",645.89,,,percent of total billed charges,,,752.57,,,percent of total billed charges,,,275.35,,,fee schedule,,,275.35,,,fee schedule,,,,,,,,
LAB ONC AML DNA DET NONDET,3121803,CDM,310,RC,0023U,CPT,,,,,,inpatient,facility,,,746,313.32,634.1,716.16,,634.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.02,,,percent of total billed charges,,,,,,,,,671.4,,,percent of total billed charges,,,716.16,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,693.78,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ONC AML DNA DET NONDET,3121803,CDM,310,RC,0023U,CPT,,,,,,outpatient,facility,,,746,313.32,201.42,716.16,,634.1,,,percent of total billed charges,,,201.42,,,percent of total billed charges,,,513.25,,,percent of total billed charges,,,502.06,,,percent of total billed charges,,,630.37,,,percent of total billed charges,,,248.51,,,fee schedule,,,649.02,,,percent of total billed charges,,,649.02,,,percent of total billed charges,,,634.1,,,percent of total billed charges,,,716.16,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,253.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",671.4,,,percent of total billed charges,,,248.51,,,fee schedule,,,693.78,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,360.34,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",335.49,,,fee schedule,,,220.68,,,fee schedule,,,220.68,,,fee schedule,,,216.27,,,fee schedule,,,248.51,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",582.63,,,percent of total billed charges,,,678.86,,,percent of total billed charges,,,248.51,,,fee schedule,,,248.51,,,fee schedule,,,,,,,,
LAB DET IA COV19 PRB AMP NS,3121811,CDM,306,RC,87635,CPT,,,,,,inpatient,facility,,,154,64.68,130.9,147.84,,130.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.98,,,percent of total billed charges,,,,,,,,,138.6,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA COV19 PRB AMP NS,3121811,CDM,306,RC,87635,CPT,,,,,,outpatient,facility,,,154,64.68,41.58,147.84,,130.9,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,105.95,,,percent of total billed charges,,,103.64,,,percent of total billed charges,,,130.13,,,percent of total billed charges,,,51.31,,,fee schedule,,,133.98,,,percent of total billed charges,,,133.98,,,percent of total billed charges,,,130.9,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,52.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",138.6,,,percent of total billed charges,,,51.31,,,fee schedule,,,143.22,,,percent of total billed charges,,,51.33,,,fee schedule,,,74.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.27,,,fee schedule,,,45.56,,,fee schedule,,,45.56,,,fee schedule,,,44.65,,,fee schedule,,,51.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",120.27,,,percent of total billed charges,,,140.14,,,percent of total billed charges,,,51.31,,,fee schedule,,,51.31,,,fee schedule,,,44.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA COV19 PRB AMP,3121829,CDM,306,RC,87635,CPT,,,,,,inpatient,facility,,,154,64.68,130.9,147.84,,130.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.98,,,percent of total billed charges,,,,,,,,,138.6,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,143.22,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA COV19 PRB AMP,3121829,CDM,306,RC,87635,CPT,,,,,,outpatient,facility,,,154,64.68,41.58,147.84,,130.9,,,percent of total billed charges,,,41.58,,,percent of total billed charges,,,105.95,,,percent of total billed charges,,,103.64,,,percent of total billed charges,,,130.13,,,percent of total billed charges,,,51.31,,,fee schedule,,,133.98,,,percent of total billed charges,,,133.98,,,percent of total billed charges,,,130.9,,,percent of total billed charges,,,147.84,,,percent of total billed charges,,,146.3,,,percent of total billed charges,,,52.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",138.6,,,percent of total billed charges,,,51.31,,,fee schedule,,,143.22,,,percent of total billed charges,,,51.33,,,fee schedule,,,74.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.27,,,fee schedule,,,45.56,,,fee schedule,,,45.56,,,fee schedule,,,44.65,,,fee schedule,,,51.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",120.27,,,percent of total billed charges,,,140.14,,,percent of total billed charges,,,51.31,,,fee schedule,,,51.31,,,fee schedule,,,44.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE SO NEOPLSM DNA TGT SEQ 324,3121845,CDM,310,RC,0037U,CPT,,,,,,inpatient,facility,,,10500,4410,8925,10080,,8925,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9135,,,percent of total billed charges,,,,,,,,,9450,,,percent of total billed charges,,,10080,,,percent of total billed charges,,,9975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9765,,,percent of total billed charges,,,9975,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE SO NEOPLSM DNA TGT SEQ 324,3121845,CDM,310,RC,0037U,CPT,,,,,,outpatient,facility,,,10500,4410,2835,10080,,8925,,,percent of total billed charges,,,2835,,,percent of total billed charges,,,7224,,,percent of total billed charges,,,7066.5,,,percent of total billed charges,,,8872.5,,,percent of total billed charges,,,3500,,,fee schedule,,,9135,,,percent of total billed charges,,,9135,,,percent of total billed charges,,,8925,,,percent of total billed charges,,,10080,,,percent of total billed charges,,,9975,,,percent of total billed charges,,,3570,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9450,,,percent of total billed charges,,,3500,,,fee schedule,,,9765,,,percent of total billed charges,,,9975,,,percent of total billed charges,,,5075,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4725,,,fee schedule,,,3108,,,fee schedule,,,3108,,,fee schedule,,,3045.84,,,fee schedule,,,3500,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",8200.5,,,percent of total billed charges,,,9555,,,percent of total billed charges,,,3500,,,fee schedule,,,3500,,,fee schedule,,,,,,,,
LAB AB SARS COV 2 COVID 19,3121910,CDM,302,RC,86769,CPT,,,,,,inpatient,facility,,,127,53.34,107.95,121.92,,107.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.49,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB SARS COV 2 COVID 19,3121910,CDM,302,RC,86769,CPT,,,,,,outpatient,facility,,,127,53.34,34.29,121.92,,107.95,,,percent of total billed charges,,,34.29,,,percent of total billed charges,,,87.38,,,percent of total billed charges,,,85.47,,,percent of total billed charges,,,107.31,,,percent of total billed charges,,,42.13,,,fee schedule,,,110.49,,,percent of total billed charges,,,110.49,,,percent of total billed charges,,,107.95,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,42.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",114.3,,,percent of total billed charges,,,42.13,,,fee schedule,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,61.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.88,,,fee schedule,,,37.41,,,fee schedule,,,37.41,,,fee schedule,,,36.66,,,fee schedule,,,42.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.19,,,percent of total billed charges,,,115.57,,,percent of total billed charges,,,42.13,,,fee schedule,,,42.13,,,fee schedule,,,41.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB SARS COV 2 COVID 19 NS,3121928,CDM,302,RC,86769,CPT,,,,,,inpatient,facility,,,127,53.34,107.95,121.92,,107.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.49,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB SARS COV 2 COVID 19 NS,3121928,CDM,302,RC,86769,CPT,,,,,,outpatient,facility,,,127,53.34,34.29,121.92,,107.95,,,percent of total billed charges,,,34.29,,,percent of total billed charges,,,87.38,,,percent of total billed charges,,,85.47,,,percent of total billed charges,,,107.31,,,percent of total billed charges,,,42.13,,,fee schedule,,,110.49,,,percent of total billed charges,,,110.49,,,percent of total billed charges,,,107.95,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,42.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",114.3,,,percent of total billed charges,,,42.13,,,fee schedule,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,61.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",56.88,,,fee schedule,,,37.41,,,fee schedule,,,37.41,,,fee schedule,,,36.66,,,fee schedule,,,42.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",99.19,,,percent of total billed charges,,,115.57,,,percent of total billed charges,,,42.13,,,fee schedule,,,42.13,,,fee schedule,,,41.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ABNORM FETAL CONGENITAL ANLYL 4,3121944,CDM,310,RC,81511,CPT,,,,,,inpatient,facility,,,490,205.8,416.5,470.4,,416.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,426.3,,,percent of total billed charges,,,,,,,,,441,,,percent of total billed charges,,,470.4,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,455.7,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ABNORM FETAL CONGENITAL ANLYL 4,3121944,CDM,310,RC,81511,CPT,,,,,,outpatient,facility,,,490,205.8,132.3,470.4,,416.5,,,percent of total billed charges,,,132.3,,,percent of total billed charges,,,337.12,,,percent of total billed charges,,,329.77,,,percent of total billed charges,,,414.05,,,percent of total billed charges,,,153.5,,,fee schedule,,,426.3,,,percent of total billed charges,,,426.3,,,percent of total billed charges,,,416.5,,,percent of total billed charges,,,470.4,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,156.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",441,,,percent of total billed charges,,,153.5,,,fee schedule,,,455.7,,,percent of total billed charges,,,465.5,,,percent of total billed charges,,,222.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",207.23,,,fee schedule,,,136.31,,,fee schedule,,,136.31,,,fee schedule,,,133.58,,,fee schedule,,,153.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",382.69,,,percent of total billed charges,,,445.9,,,percent of total billed charges,,,153.5,,,fee schedule,,,153.5,,,fee schedule,,,,,,,,
LAB HLA CLASS II PHENOTYPE QL NS,3121977,CDM,302,RC,86831,CPT,,,,,,inpatient,facility,,,246,103.32,209.1,236.16,,209.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.02,,,percent of total billed charges,,,,,,,,,221.4,,,percent of total billed charges,,,236.16,,,percent of total billed charges,,,233.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,228.78,,,percent of total billed charges,,,233.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HLA CLASS II PHENOTYPE QL NS,3121977,CDM,302,RC,86831,CPT,,,,,,outpatient,facility,,,246,103.32,66.42,236.16,,209.1,,,percent of total billed charges,,,66.42,,,percent of total billed charges,,,169.25,,,percent of total billed charges,,,165.56,,,percent of total billed charges,,,207.87,,,percent of total billed charges,,,81.88,,,fee schedule,,,214.02,,,percent of total billed charges,,,214.02,,,percent of total billed charges,,,209.1,,,percent of total billed charges,,,236.16,,,percent of total billed charges,,,233.7,,,percent of total billed charges,,,83.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",221.4,,,percent of total billed charges,,,81.88,,,fee schedule,,,228.78,,,percent of total billed charges,,,233.7,,,percent of total billed charges,,,118.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",110.54,,,fee schedule,,,72.71,,,fee schedule,,,72.71,,,fee schedule,,,71.26,,,fee schedule,,,81.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",192.13,,,percent of total billed charges,,,223.86,,,percent of total billed charges,,,81.88,,,fee schedule,,,81.88,,,fee schedule,,,83.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB HLA X MATCH NON CYTOTOXIC NS,3121985,CDM,302,RC,86825,CPT,,,,,,inpatient,facility,,,329,138.18,279.65,315.84,,279.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,286.23,,,percent of total billed charges,,,,,,,,,296.1,,,percent of total billed charges,,,315.84,,,percent of total billed charges,,,312.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,305.97,,,percent of total billed charges,,,312.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HLA X MATCH NON CYTOTOXIC NS,3121985,CDM,302,RC,86825,CPT,,,,,,outpatient,facility,,,329,138.18,68.23,315.84,,279.65,,,percent of total billed charges,,,88.83,,,percent of total billed charges,,,226.35,,,percent of total billed charges,,,221.42,,,percent of total billed charges,,,278,,,percent of total billed charges,,,109.49,,,fee schedule,,,286.23,,,percent of total billed charges,,,286.23,,,percent of total billed charges,,,279.65,,,percent of total billed charges,,,315.84,,,percent of total billed charges,,,312.55,,,percent of total billed charges,,,111.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",296.1,,,percent of total billed charges,,,109.49,,,fee schedule,,,305.97,,,percent of total billed charges,,,312.55,,,percent of total billed charges,,,158.76,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",147.81,,,fee schedule,,,97.23,,,fee schedule,,,97.23,,,fee schedule,,,95.29,,,fee schedule,,,109.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",256.95,,,percent of total billed charges,,,299.39,,,percent of total billed charges,,,109.49,,,fee schedule,,,109.49,,,fee schedule,,,68.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DIS INFCT ID FUNGAL DNA TGT 15,3121993,CDM,310,RC,0140U,CPT,,,,,,inpatient,facility,,,471,197.82,400.35,452.16,,400.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.77,,,percent of total billed charges,,,,,,,,,423.9,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIS INFCT ID FUNGAL DNA TGT 15,3121993,CDM,310,RC,0140U,CPT,,,,,,outpatient,facility,,,471,197.82,127.17,452.16,,400.35,,,percent of total billed charges,,,127.17,,,percent of total billed charges,,,324.05,,,percent of total billed charges,,,316.98,,,percent of total billed charges,,,398,,,percent of total billed charges,,,156.75,,,fee schedule,,,409.77,,,percent of total billed charges,,,409.77,,,percent of total billed charges,,,400.35,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,159.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",423.9,,,percent of total billed charges,,,156.75,,,fee schedule,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,227.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",211.61,,,fee schedule,,,139.19,,,fee schedule,,,139.19,,,fee schedule,,,136.41,,,fee schedule,,,156.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",367.85,,,percent of total billed charges,,,428.61,,,percent of total billed charges,,,156.75,,,fee schedule,,,156.75,,,fee schedule,,,,,,,,
LAB CHROMAT MS OMEGA FATTY ACIDS,3122058,CDM,301,RC,82542,CPT,,,,,,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS OMEGA FATTY ACIDS,3122058,CDM,301,RC,82542,CPT,,,,,,outpatient,facility,,,100,42,14.06,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,24.09,,,fee schedule,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,24.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",90,,,percent of total billed charges,,,24.09,,,fee schedule,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,34.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.52,,,fee schedule,,,21.39,,,fee schedule,,,21.39,,,fee schedule,,,20.96,,,fee schedule,,,24.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,24.09,,,fee schedule,,,24.09,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE F5 VAR LEIDEN NS,3122108,CDM,310,RC,81241,CPT,,,,,,inpatient,facility,,,221,92.82,187.85,212.16,,187.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,192.27,,,percent of total billed charges,,,,,,,,,198.9,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE F5 VAR LEIDEN NS,3122108,CDM,310,RC,81241,CPT,,,,,,outpatient,facility,,,221,92.82,59.67,212.16,,187.85,,,percent of total billed charges,,,59.67,,,percent of total billed charges,,,152.05,,,percent of total billed charges,,,148.73,,,percent of total billed charges,,,186.75,,,percent of total billed charges,,,73.37,,,fee schedule,,,192.27,,,percent of total billed charges,,,192.27,,,percent of total billed charges,,,187.85,,,percent of total billed charges,,,212.16,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,74.84,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",198.9,,,percent of total billed charges,,,73.37,,,fee schedule,,,205.53,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,106.39,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",99.05,,,fee schedule,,,65.15,,,fee schedule,,,65.15,,,fee schedule,,,63.85,,,fee schedule,,,73.37,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",172.6,,,percent of total billed charges,,,201.11,,,percent of total billed charges,,,73.37,,,fee schedule,,,73.37,,,fee schedule,,,64.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE TYPING HLA 1 AND2 LR VERIF NS,3122165,CDM,310,RC,81371,CPT,,,,,,inpatient,facility,,,1214,509.88,1031.9,1165.44,,1031.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1056.18,,,percent of total billed charges,,,,,,,,,1092.6,,,percent of total billed charges,,,1165.44,,,percent of total billed charges,,,1153.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1129.02,,,percent of total billed charges,,,1153.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE TYPING HLA 1 AND2 LR VERIF NS,3122165,CDM,310,RC,81371,CPT,,,,,,outpatient,facility,,,1214,509.88,327.78,1165.44,,1031.9,,,percent of total billed charges,,,327.78,,,percent of total billed charges,,,835.23,,,percent of total billed charges,,,817.02,,,percent of total billed charges,,,1025.83,,,percent of total billed charges,,,404.52,,,fee schedule,,,1056.18,,,percent of total billed charges,,,1056.18,,,percent of total billed charges,,,1031.9,,,percent of total billed charges,,,1165.44,,,percent of total billed charges,,,1153.3,,,percent of total billed charges,,,412.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1092.6,,,percent of total billed charges,,,404.52,,,fee schedule,,,1129.02,,,percent of total billed charges,,,1153.3,,,percent of total billed charges,,,586.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",546.1,,,fee schedule,,,359.21,,,fee schedule,,,359.21,,,fee schedule,,,352.03,,,fee schedule,,,404.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",948.13,,,percent of total billed charges,,,1104.74,,,percent of total billed charges,,,404.52,,,fee schedule,,,404.52,,,fee schedule,,,,,,,,
LAB GENE PIK3CA ANLYS SEQ TARGETED,3122173,CDM,310,RC,81309,CPT,,,,,,inpatient,facility,,,825,346.5,701.25,792,,701.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.75,,,percent of total billed charges,,,,,,,,,742.5,,,percent of total billed charges,,,792,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,767.25,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE PIK3CA ANLYS SEQ TARGETED,3122173,CDM,310,RC,81309,CPT,,,,,,outpatient,facility,,,825,346.5,222.75,825,,701.25,,,percent of total billed charges,,,222.75,,,percent of total billed charges,,,567.6,,,percent of total billed charges,,,555.22,,,percent of total billed charges,,,697.13,,,percent of total billed charges,,,274.83,,,fee schedule,,,717.75,,,percent of total billed charges,,,717.75,,,percent of total billed charges,,,701.25,,,percent of total billed charges,,,792,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,280.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",742.5,,,percent of total billed charges,,,274.83,,,fee schedule,,,767.25,,,percent of total billed charges,,,783.75,,,percent of total billed charges,,,398.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",371.02,,,fee schedule,,,825,,,fee schedule,,,825,,,fee schedule,,,825,,,fee schedule,,,274.83,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",644.32,,,percent of total billed charges,,,750.75,,,percent of total billed charges,,,274.83,,,fee schedule,,,274.83,,,fee schedule,,,,,,,,
LAB GENE MPL MUTATION EXON 10 ANLYS,3122199,CDM,310,RC,81339,CPT,,,,,,inpatient,facility,,,556,233.52,472.6,533.76,,472.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.72,,,percent of total billed charges,,,,,,,,,500.4,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE MPL MUTATION EXON 10 ANLYS,3122199,CDM,310,RC,81339,CPT,,,,,,outpatient,facility,,,556,233.52,150.12,556,,472.6,,,percent of total billed charges,,,150.12,,,percent of total billed charges,,,382.53,,,percent of total billed charges,,,374.19,,,percent of total billed charges,,,469.82,,,percent of total billed charges,,,185.2,,,fee schedule,,,483.72,,,percent of total billed charges,,,483.72,,,percent of total billed charges,,,472.6,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,188.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",500.4,,,percent of total billed charges,,,185.2,,,fee schedule,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,268.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",250.02,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,185.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",434.24,,,percent of total billed charges,,,505.96,,,percent of total billed charges,,,185.2,,,fee schedule,,,185.2,,,fee schedule,,,,,,,,
LAB GENE JAK2 EXON TGT SEQ 12,3122207,CDM,310,RC,81279,CPT,,,,,,inpatient,facility,,,556,233.52,472.6,533.76,,472.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.72,,,percent of total billed charges,,,,,,,,,500.4,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE JAK2 EXON TGT SEQ 12,3122207,CDM,310,RC,81279,CPT,,,,,,outpatient,facility,,,556,233.52,150.12,556,,472.6,,,percent of total billed charges,,,150.12,,,percent of total billed charges,,,382.53,,,percent of total billed charges,,,374.19,,,percent of total billed charges,,,469.82,,,percent of total billed charges,,,185.2,,,fee schedule,,,483.72,,,percent of total billed charges,,,483.72,,,percent of total billed charges,,,472.6,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,188.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",500.4,,,percent of total billed charges,,,185.2,,,fee schedule,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,268.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",250.02,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,185.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",434.24,,,percent of total billed charges,,,505.96,,,percent of total billed charges,,,185.2,,,fee schedule,,,185.2,,,fee schedule,,,,,,,,
LAB IMM MS SP100 IGG,3122215,CDM,301,RC,83516,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS SP100 IGG,3122215,CDM,301,RC,83516,CPT,,,,,,outpatient,facility,,,104,43.68,10.04,99.84,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,11.53,,,fee schedule,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",93.6,,,percent of total billed charges,,,11.53,,,fee schedule,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ URINE DAY,3122249,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ URINE DAY,3122249,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ SERUM DAY,3122256,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ SERUM DAY,3122256,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ URINE ETOH DAY,3122264,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ URINE ETOH DAY,3122264,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ URINE DAY NS,3122272,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ URINE DAY NS,3122272,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ SERUM DAY NS,3122280,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ SERUM DAY NS,3122280,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ URINE PMGT DAY,3122298,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,449,188.58,381.65,431.04,,381.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,390.63,,,percent of total billed charges,,,,,,,,,404.1,,,percent of total billed charges,,,431.04,,,percent of total billed charges,,,426.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,417.57,,,percent of total billed charges,,,426.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ URINE PMGT DAY,3122298,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,449,188.58,54.08,431.04,,381.65,,,percent of total billed charges,,,121.23,,,percent of total billed charges,,,308.91,,,percent of total billed charges,,,302.18,,,percent of total billed charges,,,379.4,,,percent of total billed charges,,,62.14,,,fee schedule,,,390.63,,,percent of total billed charges,,,390.63,,,percent of total billed charges,,,381.65,,,percent of total billed charges,,,431.04,,,percent of total billed charges,,,426.55,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",404.1,,,percent of total billed charges,,,62.14,,,fee schedule,,,417.57,,,percent of total billed charges,,,426.55,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",350.67,,,percent of total billed charges,,,408.59,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ MECON DAY NS,3122306,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ MECON DAY NS,3122306,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG SC INST ALYZ CORD BLOOD DAY,3122314,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,248,104.16,210.8,238.08,,210.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,215.76,,,percent of total billed charges,,,,,,,,,223.2,,,percent of total billed charges,,,238.08,,,percent of total billed charges,,,235.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,230.64,,,percent of total billed charges,,,235.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ CORD BLOOD DAY,3122314,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,248,104.16,54.08,238.08,,210.8,,,percent of total billed charges,,,66.96,,,percent of total billed charges,,,170.62,,,percent of total billed charges,,,166.9,,,percent of total billed charges,,,209.56,,,percent of total billed charges,,,62.14,,,fee schedule,,,215.76,,,percent of total billed charges,,,215.76,,,percent of total billed charges,,,210.8,,,percent of total billed charges,,,238.08,,,percent of total billed charges,,,235.6,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",223.2,,,percent of total billed charges,,,62.14,,,fee schedule,,,230.64,,,percent of total billed charges,,,235.6,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",193.69,,,percent of total billed charges,,,225.68,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF BUPRENORPHINE MECON DAY,3122322,CDM,301,RC,80348,CPT,,,,,,inpatient,facility,,,129,54.18,109.65,123.84,,109.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.23,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF BUPRENORPHINE MECON DAY,3122322,CDM,301,RC,80348,CPT,,,,,,outpatient,facility,,,129,54.18,34.83,129,,109.65,,,percent of total billed charges,,,34.83,,,percent of total billed charges,,,88.75,,,percent of total billed charges,,,86.82,,,percent of total billed charges,,,109,,,percent of total billed charges,,,,,,,,,112.23,,,percent of total billed charges,,,112.23,,,percent of total billed charges,,,109.65,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,116.1,,,percent of total billed charges,,,,,,,,,119.97,,,percent of total billed charges,,,122.55,,,percent of total billed charges,,,,,,,,,,,,,,,129,,,fee schedule,,,129,,,fee schedule,,,129,,,fee schedule,,,,,,,,,100.75,,,percent of total billed charges,,,117.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ CORD TISS DAY,3122330,CDM,301,RC,80307,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG SC INST ALYZ CORD TISS DAY,3122330,CDM,301,RC,80307,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,179.52,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,62.14,,,fee schedule,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,63.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",168.3,,,percent of total billed charges,,,62.14,,,fee schedule,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,90.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",83.89,,,fee schedule,,,55.18,,,fee schedule,,,55.18,,,fee schedule,,,54.08,,,fee schedule,,,62.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,62.14,,,fee schedule,,,62.14,,,fee schedule,,,70.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CULT BACT AEROBIC ID DF NS,3122389,CDM,306,RC,87077,CPT,,,,,,inpatient,facility,,,96,40.32,81.6,92.16,,81.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.52,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CULT BACT AEROBIC ID DF NS,3122389,CDM,306,RC,87077,CPT,,,,,,outpatient,facility,,,96,40.32,7.04,92.16,,81.6,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,81.12,,,percent of total billed charges,,,8.08,,,fee schedule,,,83.52,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,8.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",86.4,,,percent of total billed charges,,,8.08,,,fee schedule,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,11.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10.91,,,fee schedule,,,7.18,,,fee schedule,,,7.18,,,fee schedule,,,7.04,,,fee schedule,,,8.08,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",74.98,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,8.08,,,fee schedule,,,8.08,,,fee schedule,,,9.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ISO VIRUS ID ACT ENZYMATIC NS,3122397,CDM,306,RC,87255,CPT,,,,,,inpatient,facility,,,102,42.84,86.7,97.92,,86.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,88.74,,,percent of total billed charges,,,,,,,,,91.8,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ISO VIRUS ID ACT ENZYMATIC NS,3122397,CDM,306,RC,87255,CPT,,,,,,outpatient,facility,,,102,42.84,27.54,97.92,,86.7,,,percent of total billed charges,,,27.54,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,68.65,,,percent of total billed charges,,,86.19,,,percent of total billed charges,,,33.86,,,fee schedule,,,88.74,,,percent of total billed charges,,,88.74,,,percent of total billed charges,,,86.7,,,percent of total billed charges,,,97.92,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,34.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",91.8,,,percent of total billed charges,,,33.86,,,fee schedule,,,94.86,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,49.1,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",45.71,,,fee schedule,,,30.07,,,fee schedule,,,30.07,,,fee schedule,,,29.47,,,fee schedule,,,33.86,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",79.66,,,percent of total billed charges,,,92.82,,,percent of total billed charges,,,33.86,,,fee schedule,,,33.86,,,fee schedule,,,41.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB ISLET ENCEPHALITIS,3122496,CDM,302,RC,86341,CPT,,,,,,inpatient,facility,,,144,60.48,122.4,138.24,,122.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,125.28,,,percent of total billed charges,,,,,,,,,129.6,,,percent of total billed charges,,,138.24,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,133.92,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ISLET ENCEPHALITIS,3122496,CDM,302,RC,86341,CPT,,,,,,outpatient,facility,,,144,60.48,20.51,138.24,,122.4,,,percent of total billed charges,,,38.88,,,percent of total billed charges,,,99.07,,,percent of total billed charges,,,96.91,,,percent of total billed charges,,,121.68,,,percent of total billed charges,,,23.57,,,fee schedule,,,125.28,,,percent of total billed charges,,,125.28,,,percent of total billed charges,,,122.4,,,percent of total billed charges,,,138.24,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,24.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",129.6,,,percent of total billed charges,,,23.57,,,fee schedule,,,133.92,,,percent of total billed charges,,,136.8,,,percent of total billed charges,,,34.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",31.82,,,fee schedule,,,20.93,,,fee schedule,,,20.93,,,fee schedule,,,20.51,,,fee schedule,,,23.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",112.46,,,percent of total billed charges,,,131.04,,,percent of total billed charges,,,23.57,,,fee schedule,,,23.57,,,fee schedule,,,24.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PROT WB W INTRP ENCEPHALITIS,3122520,CDM,301,RC,84182,CPT,,,,,,inpatient,facility,,,155,65.1,131.75,148.8,,131.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,134.85,,,percent of total billed charges,,,,,,,,,139.5,,,percent of total billed charges,,,148.8,,,percent of total billed charges,,,147.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,144.15,,,percent of total billed charges,,,147.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PROT WB W INTRP ENCEPHALITIS,3122520,CDM,301,RC,84182,CPT,,,,,,outpatient,facility,,,155,65.1,22.06,148.8,,131.75,,,percent of total billed charges,,,41.85,,,percent of total billed charges,,,106.64,,,percent of total billed charges,,,104.31,,,percent of total billed charges,,,130.97,,,percent of total billed charges,,,29.21,,,fee schedule,,,134.85,,,percent of total billed charges,,,134.85,,,percent of total billed charges,,,131.75,,,percent of total billed charges,,,148.8,,,percent of total billed charges,,,147.25,,,percent of total billed charges,,,29.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",139.5,,,percent of total billed charges,,,29.21,,,fee schedule,,,144.15,,,percent of total billed charges,,,147.25,,,percent of total billed charges,,,42.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",39.43,,,fee schedule,,,25.94,,,fee schedule,,,25.94,,,fee schedule,,,25.42,,,fee schedule,,,29.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",121.06,,,percent of total billed charges,,,141.05,,,percent of total billed charges,,,29.21,,,fee schedule,,,29.21,,,fee schedule,,,22.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DIS INFCT SARS COV 2 TGT 22,3122546,CDM,310,RC,0202U,CPT,,,,,,inpatient,facility,,,1251,525.42,1063.35,1200.96,,1063.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.37,,,percent of total billed charges,,,,,,,,,1125.9,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIS INFCT SARS COV 2 TGT 22,3122546,CDM,310,RC,0202U,CPT,,,,,,outpatient,facility,,,1251,525.42,337.77,1200.96,,1063.35,,,percent of total billed charges,,,337.77,,,percent of total billed charges,,,860.69,,,percent of total billed charges,,,841.92,,,percent of total billed charges,,,1057.1,,,percent of total billed charges,,,416.78,,,fee schedule,,,1088.37,,,percent of total billed charges,,,1088.37,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,425.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1125.9,,,percent of total billed charges,,,416.78,,,fee schedule,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,604.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.65,,,fee schedule,,,370.1,,,fee schedule,,,370.1,,,fee schedule,,,362.7,,,fee schedule,,,416.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",977.03,,,percent of total billed charges,,,1138.41,,,percent of total billed charges,,,416.78,,,fee schedule,,,416.78,,,fee schedule,,,,,,,,
LAB CONSULT PATH LTD,3122553,CDM,310,RC,80503,CPT,,,,,,inpatient,facility,,,151,63.42,128.35,144.96,,128.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,131.37,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH LTD,3122553,CDM,310,RC,80503,CPT,,,,,,outpatient,facility,,,151,63.42,40.77,144.96,,128.35,,,percent of total billed charges,,,40.77,,,percent of total billed charges,,,103.89,,,percent of total billed charges,,,101.62,,,percent of total billed charges,,,127.59,,,percent of total billed charges,,,,,,,,,131.37,,,percent of total billed charges,,,131.37,,,percent of total billed charges,,,128.35,,,percent of total billed charges,,,144.96,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,135.9,,,percent of total billed charges,,,,,,,,,140.43,,,percent of total billed charges,,,143.45,,,percent of total billed charges,,,,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,54.19,,,fee schedule,,,,,,,,,117.93,,,percent of total billed charges,,,137.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH LTD,3122553,CDM,310,RC,80503,CPT,5671,APC,,,,outpatient,facility,,,151,151,27.23,80.18,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.41,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,55.3,,,fee schedule,,,,,,,,,,,,,,,80.18,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",74.66,,,fee schedule,,,,,,,,,,,,,,,,,,,,,55.3,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,55.3,,,fee schedule,,,55.3,,,fee schedule,,,27.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONSULT PATH MOD,3122561,CDM,310,RC,80504,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH MOD,3122561,CDM,310,RC,80504,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH MOD,3122561,CDM,310,RC,80504,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONSULT PATH COMP,3122579,CDM,310,RC,80505,CPT,,,,,,inpatient,facility,,,472,198.24,401.2,453.12,,401.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,410.64,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH COMP,3122579,CDM,310,RC,80505,CPT,,,,,,outpatient,facility,,,472,198.24,127.44,453.12,,401.2,,,percent of total billed charges,,,127.44,,,percent of total billed charges,,,324.74,,,percent of total billed charges,,,317.66,,,percent of total billed charges,,,398.84,,,percent of total billed charges,,,,,,,,,410.64,,,percent of total billed charges,,,410.64,,,percent of total billed charges,,,401.2,,,percent of total billed charges,,,453.12,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,424.8,,,percent of total billed charges,,,,,,,,,438.96,,,percent of total billed charges,,,448.4,,,percent of total billed charges,,,,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,170.8,,,fee schedule,,,,,,,,,368.63,,,percent of total billed charges,,,429.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH COMP,3122579,CDM,310,RC,80505,CPT,5672,APC,,,,outpatient,facility,,,472,472,85.42,252.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,177.78,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,174.29,,,fee schedule,,,,,,,,,,,,,,,252.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",235.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,174.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,174.29,,,fee schedule,,,174.29,,,fee schedule,,,85.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CONSULT PATH PROLONG ADDL 30MIN,3122587,CDM,310,RC,80506,CPT,,,,,,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CONSULT PATH PROLONG ADDL 30MIN,3122587,CDM,310,RC,80506,CPT,,,,,,outpatient,facility,,,100,42,27,100,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,,,,,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,100,,,fee schedule,,,100,,,fee schedule,,,100,,,fee schedule,,,,,,,,,78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA HEP D PCR QN,3122702,CDM,306,RC,87523,CPT,,,,,,inpatient,facility,,,690,289.8,586.5,662.4,,586.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.3,,,percent of total billed charges,,,,,,,,,621,,,percent of total billed charges,,,662.4,,,percent of total billed charges,,,655.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,641.7,,,percent of total billed charges,,,655.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA HEP D PCR QN,3122702,CDM,306,RC,87523,CPT,,,,,,outpatient,facility,,,690,289.8,42.84,690,,586.5,,,percent of total billed charges,,,186.3,,,percent of total billed charges,,,474.72,,,percent of total billed charges,,,464.37,,,percent of total billed charges,,,583.05,,,percent of total billed charges,,,42.84,,,fee schedule,,,600.3,,,percent of total billed charges,,,600.3,,,percent of total billed charges,,,586.5,,,percent of total billed charges,,,662.4,,,percent of total billed charges,,,655.5,,,percent of total billed charges,,,43.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",621,,,percent of total billed charges,,,42.84,,,fee schedule,,,641.7,,,percent of total billed charges,,,655.5,,,percent of total billed charges,,,62.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",57.83,,,fee schedule,,,690,,,fee schedule,,,690,,,fee schedule,,,690,,,fee schedule,,,42.84,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",538.89,,,percent of total billed charges,,,627.9,,,percent of total billed charges,,,42.84,,,fee schedule,,,42.84,,,fee schedule,,,,,,,,
LAB DIS INFCT ID BAC ANDFNG GRM PLUS RXRST,3122710,CDM,310,RC,0141U,CPT,,,,,,inpatient,facility,,,471,197.82,400.35,452.16,,400.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.77,,,percent of total billed charges,,,,,,,,,423.9,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIS INFCT ID BAC ANDFNG GRM PLUS RXRST,3122710,CDM,310,RC,0141U,CPT,,,,,,outpatient,facility,,,471,197.82,127.17,452.16,,400.35,,,percent of total billed charges,,,127.17,,,percent of total billed charges,,,324.05,,,percent of total billed charges,,,316.98,,,percent of total billed charges,,,398,,,percent of total billed charges,,,156.75,,,fee schedule,,,409.77,,,percent of total billed charges,,,409.77,,,percent of total billed charges,,,400.35,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,159.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",423.9,,,percent of total billed charges,,,156.75,,,fee schedule,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,227.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",211.61,,,fee schedule,,,139.19,,,fee schedule,,,139.19,,,fee schedule,,,136.41,,,fee schedule,,,156.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",367.85,,,percent of total billed charges,,,428.61,,,percent of total billed charges,,,156.75,,,fee schedule,,,156.75,,,fee schedule,,,,,,,,
LAB DIS INFCT ID BAC ANDFNG GRM  RXRST,3122728,CDM,310,RC,0142U,CPT,,,,,,inpatient,facility,,,471,197.82,400.35,452.16,,400.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.77,,,percent of total billed charges,,,,,,,,,423.9,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIS INFCT ID BAC ANDFNG GRM  RXRST,3122728,CDM,310,RC,0142U,CPT,,,,,,outpatient,facility,,,471,197.82,127.17,452.16,,400.35,,,percent of total billed charges,,,127.17,,,percent of total billed charges,,,324.05,,,percent of total billed charges,,,316.98,,,percent of total billed charges,,,398,,,percent of total billed charges,,,156.75,,,fee schedule,,,409.77,,,percent of total billed charges,,,409.77,,,percent of total billed charges,,,400.35,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,159.88,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",423.9,,,percent of total billed charges,,,156.75,,,fee schedule,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,227.29,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",211.61,,,fee schedule,,,139.19,,,fee schedule,,,139.19,,,fee schedule,,,136.41,,,fee schedule,,,156.75,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",367.85,,,percent of total billed charges,,,428.61,,,percent of total billed charges,,,156.75,,,fee schedule,,,156.75,,,fee schedule,,,,,,,,
LAB DET IA MRSA PRB AMP,3122736,CDM,306,RC,87641,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA MRSA PRB AMP,3122736,CDM,306,RC,87641,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB MITOCHONDRIAL,3122744,CDM,302,RC,86381,CPT,,,,,,inpatient,facility,,,77,32.34,65.45,73.92,,65.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,66.99,,,percent of total billed charges,,,,,,,,,69.3,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB MITOCHONDRIAL,3122744,CDM,302,RC,86381,CPT,,,,,,outpatient,facility,,,77,32.34,20.79,73.92,,65.45,,,percent of total billed charges,,,20.79,,,percent of total billed charges,,,52.98,,,percent of total billed charges,,,51.82,,,percent of total billed charges,,,65.06,,,percent of total billed charges,,,25.45,,,fee schedule,,,66.99,,,percent of total billed charges,,,66.99,,,percent of total billed charges,,,65.45,,,percent of total billed charges,,,73.92,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,25.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",69.3,,,percent of total billed charges,,,25.45,,,fee schedule,,,71.61,,,percent of total billed charges,,,73.15,,,percent of total billed charges,,,36.9,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",34.36,,,fee schedule,,,22.6,,,fee schedule,,,22.6,,,fee schedule,,,22.15,,,fee schedule,,,25.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",60.14,,,percent of total billed charges,,,70.07,,,percent of total billed charges,,,25.45,,,fee schedule,,,25.45,,,fee schedule,,,22.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AQUAPORIN 4 AB IGG CSF,3122751,CDM,302,RC,86052,CPT,,,,,,inpatient,facility,,,350,147,297.5,336,,297.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,304.5,,,percent of total billed charges,,,,,,,,,315,,,percent of total billed charges,,,336,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,325.5,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AQUAPORIN 4 AB IGG CSF,3122751,CDM,302,RC,86052,CPT,,,,,,outpatient,facility,,,350,147,10.49,336,,297.5,,,percent of total billed charges,,,94.5,,,percent of total billed charges,,,240.8,,,percent of total billed charges,,,235.55,,,percent of total billed charges,,,295.75,,,percent of total billed charges,,,12.05,,,fee schedule,,,304.5,,,percent of total billed charges,,,304.5,,,percent of total billed charges,,,297.5,,,percent of total billed charges,,,336,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",315,,,percent of total billed charges,,,12.05,,,fee schedule,,,325.5,,,percent of total billed charges,,,332.5,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",273.35,,,percent of total billed charges,,,318.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,,,,,,
LAB SCR AQUAPORIN 4 AB IGG SERUM,3122769,CDM,302,RC,86052,CPT,,,,,,inpatient,facility,,,225,94.5,191.25,216,,191.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,195.75,,,percent of total billed charges,,,,,,,,,202.5,,,percent of total billed charges,,,216,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,209.25,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AQUAPORIN 4 AB IGG SERUM,3122769,CDM,302,RC,86052,CPT,,,,,,outpatient,facility,,,225,94.5,10.49,216,,191.25,,,percent of total billed charges,,,60.75,,,percent of total billed charges,,,154.8,,,percent of total billed charges,,,151.42,,,percent of total billed charges,,,190.13,,,percent of total billed charges,,,12.05,,,fee schedule,,,195.75,,,percent of total billed charges,,,195.75,,,percent of total billed charges,,,191.25,,,percent of total billed charges,,,216,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",202.5,,,percent of total billed charges,,,12.05,,,fee schedule,,,209.25,,,percent of total billed charges,,,213.75,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",175.72,,,percent of total billed charges,,,204.75,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,,,,,,
LAB AQUAPORIN AB,3122777,CDM,302,RC,86051,CPT,,,,,,inpatient,facility,,,268,112.56,227.8,257.28,,227.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,233.16,,,percent of total billed charges,,,,,,,,,241.2,,,percent of total billed charges,,,257.28,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,249.24,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AQUAPORIN AB,3122777,CDM,302,RC,86051,CPT,,,,,,outpatient,facility,,,268,112.56,10.04,257.28,,227.8,,,percent of total billed charges,,,72.36,,,percent of total billed charges,,,184.38,,,percent of total billed charges,,,180.36,,,percent of total billed charges,,,226.46,,,percent of total billed charges,,,11.53,,,fee schedule,,,233.16,,,percent of total billed charges,,,233.16,,,percent of total billed charges,,,227.8,,,percent of total billed charges,,,257.28,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",241.2,,,percent of total billed charges,,,11.53,,,fee schedule,,,249.24,,,percent of total billed charges,,,254.6,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",209.31,,,percent of total billed charges,,,243.88,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,10.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AQUAPORIN 4 AB FLOW CYTOMETRY,3122793,CDM,302,RC,86053,CPT,,,,,,inpatient,facility,,,118,49.56,100.3,113.28,,100.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.66,,,percent of total billed charges,,,,,,,,,106.2,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AQUAPORIN 4 AB FLOW CYTOMETRY,3122793,CDM,302,RC,86053,CPT,,,,,,outpatient,facility,,,118,49.56,10.85,113.28,,100.3,,,percent of total billed charges,,,31.86,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,79.41,,,percent of total billed charges,,,99.71,,,percent of total billed charges,,,37.73,,,fee schedule,,,102.66,,,percent of total billed charges,,,102.66,,,percent of total billed charges,,,100.3,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,38.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",106.2,,,percent of total billed charges,,,37.73,,,fee schedule,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,54.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",50.94,,,fee schedule,,,33.5,,,fee schedule,,,33.5,,,fee schedule,,,32.83,,,fee schedule,,,37.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",92.16,,,percent of total billed charges,,,107.38,,,percent of total billed charges,,,37.73,,,fee schedule,,,37.73,,,fee schedule,,,10.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GLUCOSE BLOOD REAGENT STRIP,3122835,CDM,301,RC,82948,CPT,,,,,,inpatient,facility,,,16,6.72,13.6,15.36,,13.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13.92,,,percent of total billed charges,,,,,,,,,14.4,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GLUCOSE BLOOD REAGENT STRIP,3122835,CDM,301,RC,82948,CPT,,,,,,outpatient,facility,,,16,6.72,2.34,15.36,,13.6,,,percent of total billed charges,,,4.32,,,percent of total billed charges,,,11.01,,,percent of total billed charges,,,10.77,,,percent of total billed charges,,,13.52,,,percent of total billed charges,,,5.04,,,fee schedule,,,13.92,,,percent of total billed charges,,,13.92,,,percent of total billed charges,,,13.6,,,percent of total billed charges,,,15.36,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,5.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.4,,,percent of total billed charges,,,5.04,,,fee schedule,,,14.88,,,percent of total billed charges,,,15.2,,,percent of total billed charges,,,7.31,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6.8,,,fee schedule,,,4.48,,,fee schedule,,,4.48,,,fee schedule,,,4.39,,,fee schedule,,,5.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",12.5,,,percent of total billed charges,,,14.56,,,percent of total billed charges,,,5.04,,,fee schedule,,,5.04,,,fee schedule,,,2.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
WELLNESS CBC AUTO WO DIFF,3122850,CDM,301,RC,,,,,,,,inpatient,facility,,,20,8.4,17,19.2,,17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17.4,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS CBC AUTO WO DIFF,3122850,CDM,301,RC,,,,,,,,outpatient,facility,,,20,8.4,5.4,20,,17,,,percent of total billed charges,,,5.4,,,percent of total billed charges,,,13.76,,,percent of total billed charges,,,13.46,,,percent of total billed charges,,,16.9,,,percent of total billed charges,,,,,,,,,17.4,,,percent of total billed charges,,,17.4,,,percent of total billed charges,,,17,,,percent of total billed charges,,,19.2,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,18,,,percent of total billed charges,,,,,,,,,18.6,,,percent of total billed charges,,,19,,,percent of total billed charges,,,,,,,,,,,,,,,20,,,fee schedule,,,20,,,fee schedule,,,20,,,fee schedule,,,,,,,,,15.62,,,percent of total billed charges,,,18.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB IMM MS GP210 IGG,3122926,CDM,300,RC,83516,CPT,,,,,,inpatient,facility,,,148,62.16,125.8,142.08,,125.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,128.76,,,percent of total billed charges,,,,,,,,,133.2,,,percent of total billed charges,,,142.08,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,137.64,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS GP210 IGG,3122926,CDM,300,RC,83516,CPT,,,,,,outpatient,facility,,,148,62.16,10.04,142.08,,125.8,,,percent of total billed charges,,,39.96,,,percent of total billed charges,,,101.82,,,percent of total billed charges,,,99.6,,,percent of total billed charges,,,125.06,,,percent of total billed charges,,,11.53,,,fee schedule,,,128.76,,,percent of total billed charges,,,128.76,,,percent of total billed charges,,,125.8,,,percent of total billed charges,,,142.08,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",133.2,,,percent of total billed charges,,,11.53,,,fee schedule,,,137.64,,,percent of total billed charges,,,140.6,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",115.59,,,percent of total billed charges,,,134.68,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB ADAMTS 13,3122983,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,300,126,255,288,,255,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB ADAMTS 13,3122983,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,300,126,15.03,288,,255,,,percent of total billed charges,,,81,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,201.9,,,percent of total billed charges,,,253.5,,,percent of total billed charges,,,17.27,,,fee schedule,,,261,,,percent of total billed charges,,,261,,,percent of total billed charges,,,255,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",270,,,percent of total billed charges,,,17.27,,,fee schedule,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",234.3,,,percent of total billed charges,,,273,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB TOXOPLASMA IGA,3123056,CDM,302,RC,86777,CPT,,,,,,inpatient,facility,,,166,69.72,141.1,159.36,,141.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,144.42,,,percent of total billed charges,,,,,,,,,149.4,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB TOXOPLASMA IGA,3123056,CDM,302,RC,86777,CPT,,,,,,outpatient,facility,,,166,69.72,12.52,159.36,,141.1,,,percent of total billed charges,,,44.82,,,percent of total billed charges,,,114.21,,,percent of total billed charges,,,111.72,,,percent of total billed charges,,,140.27,,,percent of total billed charges,,,14.39,,,fee schedule,,,144.42,,,percent of total billed charges,,,144.42,,,percent of total billed charges,,,141.1,,,percent of total billed charges,,,159.36,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,14.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",149.4,,,percent of total billed charges,,,14.39,,,fee schedule,,,154.38,,,percent of total billed charges,,,157.7,,,percent of total billed charges,,,20.87,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.43,,,fee schedule,,,12.78,,,fee schedule,,,12.78,,,fee schedule,,,12.52,,,fee schedule,,,14.39,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",129.65,,,percent of total billed charges,,,151.06,,,percent of total billed charges,,,14.39,,,fee schedule,,,14.39,,,fee schedule,,,17.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IGH BCL2 TRAN MBR ANDMCR REG ANLYS,3123064,CDM,310,RC,81278,CPT,,,,,,inpatient,facility,,,622,261.24,528.7,597.12,,528.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,541.14,,,percent of total billed charges,,,,,,,,,559.8,,,percent of total billed charges,,,597.12,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,578.46,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IGH BCL2 TRAN MBR ANDMCR REG ANLYS,3123064,CDM,310,RC,81278,CPT,,,,,,outpatient,facility,,,622,261.24,167.94,622,,528.7,,,percent of total billed charges,,,167.94,,,percent of total billed charges,,,427.94,,,percent of total billed charges,,,418.61,,,percent of total billed charges,,,525.59,,,percent of total billed charges,,,207.31,,,fee schedule,,,541.14,,,percent of total billed charges,,,541.14,,,percent of total billed charges,,,528.7,,,percent of total billed charges,,,597.12,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,211.46,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",559.8,,,percent of total billed charges,,,207.31,,,fee schedule,,,578.46,,,percent of total billed charges,,,590.9,,,percent of total billed charges,,,300.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",279.87,,,fee schedule,,,622,,,fee schedule,,,622,,,fee schedule,,,622,,,fee schedule,,,207.31,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",485.78,,,percent of total billed charges,,,566.02,,,percent of total billed charges,,,207.31,,,fee schedule,,,207.31,,,fee schedule,,,,,,,,
LAB AB ENA PM SC1 100,3123072,CDM,302,RC,86235,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB ENA PM SC1 100,3123072,CDM,302,RC,86235,CPT,,,,,,outpatient,facility,,,115,48.3,15.6,110.4,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,17.93,,,fee schedule,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",103.5,,,percent of total billed charges,,,17.93,,,fee schedule,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,21.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM MS POLYMERASE III AB,3123080,CDM,300,RC,83516,CPT,,,,,,inpatient,facility,,,107,44.94,90.95,102.72,,90.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,93.09,,,percent of total billed charges,,,,,,,,,96.3,,,percent of total billed charges,,,102.72,,,percent of total billed charges,,,101.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,99.51,,,percent of total billed charges,,,101.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM MS POLYMERASE III AB,3123080,CDM,300,RC,83516,CPT,,,,,,outpatient,facility,,,107,44.94,10.04,102.72,,90.95,,,percent of total billed charges,,,28.89,,,percent of total billed charges,,,73.62,,,percent of total billed charges,,,72.01,,,percent of total billed charges,,,90.41,,,percent of total billed charges,,,11.53,,,fee schedule,,,93.09,,,percent of total billed charges,,,93.09,,,percent of total billed charges,,,90.95,,,percent of total billed charges,,,102.72,,,percent of total billed charges,,,101.65,,,percent of total billed charges,,,11.76,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",96.3,,,percent of total billed charges,,,11.53,,,fee schedule,,,99.51,,,percent of total billed charges,,,101.65,,,percent of total billed charges,,,16.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15.57,,,fee schedule,,,10.24,,,fee schedule,,,10.24,,,fee schedule,,,10.04,,,fee schedule,,,11.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",83.57,,,percent of total billed charges,,,97.37,,,percent of total billed charges,,,11.53,,,fee schedule,,,11.53,,,fee schedule,,,14.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
WELLNESS CULT STREP GROUP A,3123098,CDM,306,RC,,,,,,,,inpatient,facility,,,25,10.5,21.25,24,,21.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS CULT STREP GROUP A,3123098,CDM,306,RC,,,,,,,,outpatient,facility,,,25,10.5,6.75,25,,21.25,,,percent of total billed charges,,,6.75,,,percent of total billed charges,,,17.2,,,percent of total billed charges,,,16.82,,,percent of total billed charges,,,21.13,,,percent of total billed charges,,,,,,,,,21.75,,,percent of total billed charges,,,21.75,,,percent of total billed charges,,,21.25,,,percent of total billed charges,,,24,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,22.5,,,percent of total billed charges,,,,,,,,,23.25,,,percent of total billed charges,,,23.75,,,percent of total billed charges,,,,,,,,,,,,,,,25,,,fee schedule,,,25,,,fee schedule,,,25,,,fee schedule,,,,,,,,,19.52,,,percent of total billed charges,,,22.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
WELLNESS DEHYDROEPIANDROSTERON SULF,3123106,CDM,301,RC,,,,,,,,inpatient,facility,,,35,14.7,29.75,33.6,,29.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30.45,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
WELLNESS DEHYDROEPIANDROSTERON SULF,3123106,CDM,301,RC,,,,,,,,outpatient,facility,,,35,14.7,9.45,35,,29.75,,,percent of total billed charges,,,9.45,,,percent of total billed charges,,,24.08,,,percent of total billed charges,,,23.55,,,percent of total billed charges,,,29.57,,,percent of total billed charges,,,,,,,,,30.45,,,percent of total billed charges,,,30.45,,,percent of total billed charges,,,29.75,,,percent of total billed charges,,,33.6,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,31.5,,,percent of total billed charges,,,,,,,,,32.55,,,percent of total billed charges,,,33.25,,,percent of total billed charges,,,,,,,,,,,,,,,35,,,fee schedule,,,35,,,fee schedule,,,35,,,fee schedule,,,,,,,,,27.34,,,percent of total billed charges,,,31.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
LAB DET IA ORTHOPOXVIRUS PRB AMP,3123122,CDM,306,RC,87593,CPT,,,,,,inpatient,facility,,,85,35.7,72.25,81.6,,72.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,,,,,,,,76.5,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA ORTHOPOXVIRUS PRB AMP,3123122,CDM,306,RC,87593,CPT,,,,,,outpatient,facility,,,85,35.7,22.95,81.6,,72.25,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,58.48,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,71.83,,,percent of total billed charges,,,,,,,,,73.95,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,72.25,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,76.5,,,percent of total billed charges,,,,,,,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,68.38,,,fee schedule,,,68.38,,,fee schedule,,,67.01,,,fee schedule,,,,,,,,,66.38,,,percent of total billed charges,,,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,31.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ALLG IGE QN SEMI QN EA NS,3123148,CDM,302,RC,86008,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ALLG IGE QN SEMI QN EA NS,3123148,CDM,302,RC,86008,CPT,,,,,,outpatient,facility,,,80,33.6,15.6,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,17.93,,,fee schedule,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,18.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",72,,,percent of total billed charges,,,17.93,,,fee schedule,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24.21,,,fee schedule,,,15.92,,,fee schedule,,,15.92,,,fee schedule,,,15.6,,,fee schedule,,,17.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,17.93,,,fee schedule,,,17.93,,,fee schedule,,,19.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM VWF BINDING ASSAY,3123155,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,145,60.9,123.25,139.2,,123.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,126.15,,,percent of total billed charges,,,,,,,,,130.5,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,134.85,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM VWF BINDING ASSAY,3123155,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,145,60.9,15.03,139.2,,123.25,,,percent of total billed charges,,,39.15,,,percent of total billed charges,,,99.76,,,percent of total billed charges,,,97.58,,,percent of total billed charges,,,122.52,,,percent of total billed charges,,,17.27,,,fee schedule,,,126.15,,,percent of total billed charges,,,126.15,,,percent of total billed charges,,,123.25,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",130.5,,,percent of total billed charges,,,17.27,,,fee schedule,,,134.85,,,percent of total billed charges,,,137.75,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",113.25,,,percent of total billed charges,,,131.95,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CHLORDIAZEPOXIDE,3123171,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,169,70.98,143.65,162.24,,143.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,147.03,,,percent of total billed charges,,,,,,,,,152.1,,,percent of total billed charges,,,162.24,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,157.17,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHLORDIAZEPOXIDE,3123171,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,169,70.98,16.22,162.24,,143.65,,,percent of total billed charges,,,45.63,,,percent of total billed charges,,,116.27,,,percent of total billed charges,,,113.74,,,percent of total billed charges,,,142.81,,,percent of total billed charges,,,18.64,,,fee schedule,,,147.03,,,percent of total billed charges,,,147.03,,,percent of total billed charges,,,143.65,,,percent of total billed charges,,,162.24,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",152.1,,,percent of total billed charges,,,18.64,,,fee schedule,,,157.17,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",131.99,,,percent of total billed charges,,,153.79,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB METHOTREXATE NS,3123197,CDM,301,RC,80204,CPT,,,,,,inpatient,facility,,,116,48.72,98.6,111.36,,98.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.92,,,percent of total billed charges,,,,,,,,,104.4,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB METHOTREXATE NS,3123197,CDM,301,RC,80204,CPT,,,,,,outpatient,facility,,,116,48.72,31.32,111.36,,98.6,,,percent of total billed charges,,,31.32,,,percent of total billed charges,,,79.81,,,percent of total billed charges,,,78.07,,,percent of total billed charges,,,98.02,,,percent of total billed charges,,,38.57,,,fee schedule,,,100.92,,,percent of total billed charges,,,100.92,,,percent of total billed charges,,,98.6,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,39.34,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",104.4,,,percent of total billed charges,,,38.57,,,fee schedule,,,107.88,,,percent of total billed charges,,,110.2,,,percent of total billed charges,,,55.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",52.07,,,fee schedule,,,34.25,,,fee schedule,,,34.25,,,fee schedule,,,33.57,,,fee schedule,,,38.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",90.6,,,percent of total billed charges,,,105.56,,,percent of total billed charges,,,38.57,,,fee schedule,,,38.57,,,fee schedule,,,33.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SEMEN VOL COUNT MOT ANDDIF W MORPH,3123221,CDM,300,RC,89322,CPT,,,,,,inpatient,facility,,,418,175.56,355.3,401.28,,355.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,363.66,,,percent of total billed charges,,,,,,,,,376.2,,,percent of total billed charges,,,401.28,,,percent of total billed charges,,,397.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,388.74,,,percent of total billed charges,,,397.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SEMEN VOL COUNT MOT ANDDIF W MORPH,3123221,CDM,300,RC,89322,CPT,,,,,,outpatient,facility,,,418,175.56,13.48,401.28,,355.3,,,percent of total billed charges,,,112.86,,,percent of total billed charges,,,287.58,,,percent of total billed charges,,,281.31,,,percent of total billed charges,,,353.21,,,percent of total billed charges,,,15.5,,,fee schedule,,,363.66,,,percent of total billed charges,,,363.66,,,percent of total billed charges,,,355.3,,,percent of total billed charges,,,401.28,,,percent of total billed charges,,,397.1,,,percent of total billed charges,,,15.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",376.2,,,percent of total billed charges,,,15.5,,,fee schedule,,,388.74,,,percent of total billed charges,,,397.1,,,percent of total billed charges,,,22.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",20.93,,,fee schedule,,,13.76,,,fee schedule,,,13.76,,,fee schedule,,,13.48,,,fee schedule,,,15.5,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",326.46,,,percent of total billed charges,,,380.38,,,percent of total billed charges,,,15.5,,,fee schedule,,,15.5,,,fee schedule,,,19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB HTLV HIV CONFIRM DONOR NS,3123247,CDM,302,RC,86689,CPT,,,,,,inpatient,facility,,,503,211.26,427.55,482.88,,427.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,437.61,,,percent of total billed charges,,,,,,,,,452.7,,,percent of total billed charges,,,482.88,,,percent of total billed charges,,,477.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,467.79,,,percent of total billed charges,,,477.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB HTLV HIV CONFIRM DONOR NS,3123247,CDM,302,RC,86689,CPT,,,,,,outpatient,facility,,,503,211.26,16.84,482.88,,427.55,,,percent of total billed charges,,,135.81,,,percent of total billed charges,,,346.06,,,percent of total billed charges,,,338.52,,,percent of total billed charges,,,425.03,,,percent of total billed charges,,,19.35,,,fee schedule,,,437.61,,,percent of total billed charges,,,437.61,,,percent of total billed charges,,,427.55,,,percent of total billed charges,,,482.88,,,percent of total billed charges,,,477.85,,,percent of total billed charges,,,19.74,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",452.7,,,percent of total billed charges,,,19.35,,,fee schedule,,,467.79,,,percent of total billed charges,,,477.85,,,percent of total billed charges,,,28.06,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",26.12,,,fee schedule,,,17.18,,,fee schedule,,,17.18,,,fee schedule,,,16.84,,,fee schedule,,,19.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",392.84,,,percent of total billed charges,,,457.73,,,percent of total billed charges,,,19.35,,,fee schedule,,,19.35,,,fee schedule,,,23.73,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB PLASMINOGEN NON ANTIGENIC NS,3123254,CDM,305,RC,85420,CPT,,,,,,inpatient,facility,,,71,29.82,60.35,68.16,,60.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,61.77,,,percent of total billed charges,,,,,,,,,63.9,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB PLASMINOGEN NON ANTIGENIC NS,3123254,CDM,305,RC,85420,CPT,,,,,,outpatient,facility,,,71,29.82,5.68,68.16,,60.35,,,percent of total billed charges,,,19.17,,,percent of total billed charges,,,48.85,,,percent of total billed charges,,,47.78,,,percent of total billed charges,,,59.99,,,percent of total billed charges,,,6.53,,,fee schedule,,,61.77,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,60.35,,,percent of total billed charges,,,68.16,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,6.66,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",63.9,,,percent of total billed charges,,,6.53,,,fee schedule,,,66.03,,,percent of total billed charges,,,67.45,,,percent of total billed charges,,,9.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",8.82,,,fee schedule,,,5.8,,,fee schedule,,,5.8,,,fee schedule,,,5.68,,,fee schedule,,,6.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",55.45,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,6.53,,,fee schedule,,,6.53,,,fee schedule,,,6.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IG PARAPROT IMPRC ANDMS BLD UR QL,3123270,CDM,310,RC,0077U,CPT,,,,,,inpatient,facility,,,206,86.52,175.1,197.76,,175.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,179.22,,,percent of total billed charges,,,,,,,,,185.4,,,percent of total billed charges,,,197.76,,,percent of total billed charges,,,195.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,191.58,,,percent of total billed charges,,,195.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IG PARAPROT IMPRC ANDMS BLD UR QL,3123270,CDM,310,RC,0077U,CPT,,,,,,outpatient,facility,,,206,86.52,37.8,197.76,,175.1,,,percent of total billed charges,,,55.62,,,percent of total billed charges,,,141.73,,,percent of total billed charges,,,138.64,,,percent of total billed charges,,,174.07,,,percent of total billed charges,,,43.43,,,fee schedule,,,179.22,,,percent of total billed charges,,,179.22,,,percent of total billed charges,,,175.1,,,percent of total billed charges,,,197.76,,,percent of total billed charges,,,195.7,,,percent of total billed charges,,,44.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",185.4,,,percent of total billed charges,,,43.43,,,fee schedule,,,191.58,,,percent of total billed charges,,,195.7,,,percent of total billed charges,,,62.97,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.63,,,fee schedule,,,38.57,,,fee schedule,,,38.57,,,fee schedule,,,37.8,,,fee schedule,,,43.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",160.89,,,percent of total billed charges,,,187.46,,,percent of total billed charges,,,43.43,,,fee schedule,,,43.43,,,fee schedule,,,,,,,,
LAB TB MEAS IMMUNITY T CELL SUSP NS,3123288,CDM,302,RC,86481,CPT,,,,,,inpatient,facility,,,300,126,255,288,,255,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB TB MEAS IMMUNITY T CELL SUSP NS,3123288,CDM,302,RC,86481,CPT,,,,,,outpatient,facility,,,300,126,81,288,,255,,,percent of total billed charges,,,81,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,201.9,,,percent of total billed charges,,,253.5,,,percent of total billed charges,,,100,,,fee schedule,,,261,,,percent of total billed charges,,,261,,,percent of total billed charges,,,255,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,102,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",270,,,percent of total billed charges,,,100,,,fee schedule,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,145,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",135,,,fee schedule,,,88.8,,,fee schedule,,,88.8,,,fee schedule,,,87.02,,,fee schedule,,,100,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",234.3,,,percent of total billed charges,,,273,,,percent of total billed charges,,,100,,,fee schedule,,,100,,,fee schedule,,,,,,,,
LAB IMM ANALYTE CYTOKINES QN,3123296,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,135,56.7,114.75,129.6,,114.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,117.45,,,percent of total billed charges,,,,,,,,,121.5,,,percent of total billed charges,,,129.6,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,125.55,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM ANALYTE CYTOKINES QN,3123296,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,135,56.7,15.03,129.6,,114.75,,,percent of total billed charges,,,36.45,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,90.85,,,percent of total billed charges,,,114.08,,,percent of total billed charges,,,17.27,,,fee schedule,,,117.45,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,114.75,,,percent of total billed charges,,,129.6,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",121.5,,,percent of total billed charges,,,17.27,,,fee schedule,,,125.55,,,percent of total billed charges,,,128.25,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",105.44,,,percent of total billed charges,,,122.85,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT AG SC5B 9 COMP EA,3123320,CDM,302,RC,86160,CPT,,,,,,inpatient,facility,,,292,122.64,248.2,280.32,,248.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,254.04,,,percent of total billed charges,,,,,,,,,262.8,,,percent of total billed charges,,,280.32,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,271.56,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT AG SC5B 9 COMP EA,3123320,CDM,302,RC,86160,CPT,,,,,,outpatient,facility,,,292,122.64,10.45,280.32,,248.2,,,percent of total billed charges,,,78.84,,,percent of total billed charges,,,200.9,,,percent of total billed charges,,,196.52,,,percent of total billed charges,,,246.74,,,percent of total billed charges,,,12,,,fee schedule,,,254.04,,,percent of total billed charges,,,254.04,,,percent of total billed charges,,,248.2,,,percent of total billed charges,,,280.32,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",262.8,,,percent of total billed charges,,,12,,,fee schedule,,,271.56,,,percent of total billed charges,,,277.4,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",228.05,,,percent of total billed charges,,,265.72,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DIS INFCT BAC VAG RNA VG FLU QN,3123361,CDM,310,RC,81513,CPT,,,,,,inpatient,facility,,,428,179.76,363.8,410.88,,363.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,372.36,,,percent of total billed charges,,,,,,,,,385.2,,,percent of total billed charges,,,410.88,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,398.04,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIS INFCT BAC VAG RNA VG FLU QN,3123361,CDM,310,RC,81513,CPT,,,,,,outpatient,facility,,,428,179.76,115.56,410.88,,363.8,,,percent of total billed charges,,,115.56,,,percent of total billed charges,,,294.46,,,percent of total billed charges,,,288.04,,,percent of total billed charges,,,361.66,,,percent of total billed charges,,,142.63,,,fee schedule,,,372.36,,,percent of total billed charges,,,372.36,,,percent of total billed charges,,,363.8,,,percent of total billed charges,,,410.88,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,145.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",385.2,,,percent of total billed charges,,,142.63,,,fee schedule,,,398.04,,,percent of total billed charges,,,406.6,,,percent of total billed charges,,,206.81,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",192.55,,,fee schedule,,,126.66,,,fee schedule,,,126.66,,,fee schedule,,,124.13,,,fee schedule,,,142.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",334.27,,,percent of total billed charges,,,389.48,,,percent of total billed charges,,,142.63,,,fee schedule,,,142.63,,,fee schedule,,,,,,,,
LAB AB M FAENI,3123395,CDM,302,RC,86609,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB M FAENI,3123395,CDM,302,RC,86609,CPT,,,,,,outpatient,facility,,,153,64.26,11.21,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,12.88,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB S VIRIDIS,3123403,CDM,302,RC,86609,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB S VIRIDIS,3123403,CDM,302,RC,86609,CPT,,,,,,outpatient,facility,,,153,64.26,11.21,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,12.88,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB T CANDIDUS,3123411,CDM,302,RC,86609,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB T CANDIDUS,3123411,CDM,302,RC,86609,CPT,,,,,,outpatient,facility,,,153,64.26,11.21,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,12.88,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB T VULGARIS,3123429,CDM,302,RC,86609,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB T VULGARIS,3123429,CDM,302,RC,86609,CPT,,,,,,outpatient,facility,,,153,64.26,11.21,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,12.88,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB LISTERIA,3123437,CDM,302,RC,86609,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB LISTERIA,3123437,CDM,302,RC,86609,CPT,,,,,,outpatient,facility,,,153,64.26,11.21,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,12.88,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,13.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,12.88,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,18.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.39,,,fee schedule,,,11.44,,,fee schedule,,,11.44,,,fee schedule,,,11.21,,,fee schedule,,,12.88,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,12.88,,,fee schedule,,,12.88,,,fee schedule,,,15.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CYSTICERCUS CSF,3123445,CDM,302,RC,86682,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CYSTICERCUS CSF,3123445,CDM,302,RC,86682,CPT,,,,,,outpatient,facility,,,65,27.3,11.32,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.01,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.01,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,18.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.56,,,fee schedule,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,11.32,,,fee schedule,,,13.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.01,,,fee schedule,,,13.01,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB CYSTICERCUS SERUM,3123452,CDM,302,RC,86682,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB CYSTICERCUS SERUM,3123452,CDM,302,RC,86682,CPT,,,,,,outpatient,facility,,,65,27.3,11.32,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.01,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.01,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,18.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.56,,,fee schedule,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,11.32,,,fee schedule,,,13.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.01,,,fee schedule,,,13.01,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB AB SCHISTOSOMA SERUM,3123460,CDM,302,RC,86682,CPT,,,,,,inpatient,facility,,,65,27.3,55.25,62.4,,55.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.55,,,percent of total billed charges,,,,,,,,,58.5,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB AB SCHISTOSOMA SERUM,3123460,CDM,302,RC,86682,CPT,,,,,,outpatient,facility,,,65,27.3,11.32,62.4,,55.25,,,percent of total billed charges,,,17.55,,,percent of total billed charges,,,44.72,,,percent of total billed charges,,,43.74,,,percent of total billed charges,,,54.92,,,percent of total billed charges,,,13.01,,,fee schedule,,,56.55,,,percent of total billed charges,,,56.55,,,percent of total billed charges,,,55.25,,,percent of total billed charges,,,62.4,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,13.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",58.5,,,percent of total billed charges,,,13.01,,,fee schedule,,,60.45,,,percent of total billed charges,,,61.75,,,percent of total billed charges,,,18.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",17.56,,,fee schedule,,,11.55,,,fee schedule,,,11.55,,,fee schedule,,,11.32,,,fee schedule,,,13.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",50.77,,,percent of total billed charges,,,59.15,,,percent of total billed charges,,,13.01,,,fee schedule,,,13.01,,,fee schedule,,,12.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF FUROSEMIDE DAY 1 3,3123478,CDM,301,RC,80375,CPT,,,,,,inpatient,facility,,,181,76.02,153.85,173.76,,153.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.47,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF FUROSEMIDE DAY 1 3,3123478,CDM,301,RC,80375,CPT,,,,,,outpatient,facility,,,181,76.02,16.89,181,,153.85,,,percent of total billed charges,,,48.87,,,percent of total billed charges,,,124.53,,,percent of total billed charges,,,121.81,,,percent of total billed charges,,,152.94,,,percent of total billed charges,,,,,,,,,157.47,,,percent of total billed charges,,,157.47,,,percent of total billed charges,,,153.85,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,181,,,fee schedule,,,181,,,fee schedule,,,181,,,fee schedule,,,,,,,,,141.36,,,percent of total billed charges,,,164.71,,,percent of total billed charges,,,,,,,,,,,,,,,16.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF MITOTANE DAY 1 3,3123486,CDM,301,RC,80375,CPT,,,,,,inpatient,facility,,,181,76.02,153.85,173.76,,153.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.47,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF MITOTANE DAY 1 3,3123486,CDM,301,RC,80375,CPT,,,,,,outpatient,facility,,,181,76.02,16.89,181,,153.85,,,percent of total billed charges,,,48.87,,,percent of total billed charges,,,124.53,,,percent of total billed charges,,,121.81,,,percent of total billed charges,,,152.94,,,percent of total billed charges,,,,,,,,,157.47,,,percent of total billed charges,,,157.47,,,percent of total billed charges,,,153.85,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,181,,,fee schedule,,,181,,,fee schedule,,,181,,,fee schedule,,,,,,,,,141.36,,,percent of total billed charges,,,164.71,,,percent of total billed charges,,,,,,,,,,,,,,,16.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DRG DF TPMT ACTIVITY DAY 1 3,3123494,CDM,301,RC,80375,CPT,,,,,,inpatient,facility,,,181,76.02,153.85,173.76,,153.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.47,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DRG DF TPMT ACTIVITY DAY 1 3,3123494,CDM,301,RC,80375,CPT,,,,,,outpatient,facility,,,181,76.02,16.89,181,,153.85,,,percent of total billed charges,,,48.87,,,percent of total billed charges,,,124.53,,,percent of total billed charges,,,121.81,,,percent of total billed charges,,,152.94,,,percent of total billed charges,,,,,,,,,157.47,,,percent of total billed charges,,,157.47,,,percent of total billed charges,,,153.85,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,181,,,fee schedule,,,181,,,fee schedule,,,181,,,fee schedule,,,,,,,,,141.36,,,percent of total billed charges,,,164.71,,,percent of total billed charges,,,,,,,,,,,,,,,16.89,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB THIOPURINE S METHYLTRANSFERASE,3123569,CDM,301,RC,84433,CPT,,,,,,inpatient,facility,,,112,47.04,95.2,107.52,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB THIOPURINE S METHYLTRANSFERASE,3123569,CDM,301,RC,84433,CPT,,,,,,outpatient,facility,,,112,47.04,19.3,107.52,,95.2,,,percent of total billed charges,,,30.24,,,percent of total billed charges,,,77.06,,,percent of total billed charges,,,75.38,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,22.17,,,fee schedule,,,97.44,,,percent of total billed charges,,,97.44,,,percent of total billed charges,,,95.2,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,22.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",100.8,,,percent of total billed charges,,,22.17,,,fee schedule,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,32.15,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",29.93,,,fee schedule,,,19.69,,,fee schedule,,,19.69,,,fee schedule,,,19.3,,,fee schedule,,,22.17,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",87.47,,,percent of total billed charges,,,101.92,,,percent of total billed charges,,,22.17,,,fee schedule,,,22.17,,,fee schedule,,,19.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB COMPLEMENT ACT FUNC C3NEF,3123577,CDM,302,RC,86161,CPT,,,,,,inpatient,facility,,,300,126,255,288,,255,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,261,,,percent of total billed charges,,,,,,,,,270,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB COMPLEMENT ACT FUNC C3NEF,3123577,CDM,302,RC,86161,CPT,,,,,,outpatient,facility,,,300,126,10.45,288,,255,,,percent of total billed charges,,,81,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,201.9,,,percent of total billed charges,,,253.5,,,percent of total billed charges,,,12,,,fee schedule,,,261,,,percent of total billed charges,,,261,,,percent of total billed charges,,,255,,,percent of total billed charges,,,288,,,percent of total billed charges,,,285,,,percent of total billed charges,,,12.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",270,,,percent of total billed charges,,,12,,,fee schedule,,,279,,,percent of total billed charges,,,285,,,percent of total billed charges,,,17.4,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.2,,,fee schedule,,,10.66,,,fee schedule,,,10.66,,,fee schedule,,,10.45,,,fee schedule,,,12,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",234.3,,,percent of total billed charges,,,273,,,percent of total billed charges,,,12,,,fee schedule,,,12,,,fee schedule,,,14.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GSAP METAB RX  MORE THAN6,3123767,CDM,310,RC,81418,CPT,,,,,,inpatient,facility,,,228,95.76,193.8,218.88,,193.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.36,,,percent of total billed charges,,,,,,,,,205.2,,,percent of total billed charges,,,218.88,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,212.04,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GSAP METAB RX  MORE THAN6,3123767,CDM,310,RC,81418,CPT,,,,,,outpatient,facility,,,228,95.76,61.56,330.6,,193.8,,,percent of total billed charges,,,61.56,,,percent of total billed charges,,,156.86,,,percent of total billed charges,,,153.44,,,percent of total billed charges,,,192.66,,,percent of total billed charges,,,228,,,fee schedule,,,198.36,,,percent of total billed charges,,,198.36,,,percent of total billed charges,,,193.8,,,percent of total billed charges,,,218.88,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,232.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",205.2,,,percent of total billed charges,,,228,,,fee schedule,,,212.04,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,330.6,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",307.8,,,fee schedule,,,228,,,fee schedule,,,228,,,fee schedule,,,223.44,,,fee schedule,,,228,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",178.07,,,percent of total billed charges,,,207.48,,,percent of total billed charges,,,228,,,fee schedule,,,228,,,fee schedule,,,,,,,,
LAB CRYOFIBRINOGEN MAYO NS,3123775,CDM,301,RC,82585,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CRYOFIBRINOGEN MAYO NS,3123775,CDM,301,RC,82585,CPT,,,,,,outpatient,facility,,,153,64.26,10.51,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,14.14,,,fee schedule,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,14.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",137.7,,,percent of total billed charges,,,14.14,,,fee schedule,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,20.5,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",19.09,,,fee schedule,,,12.56,,,fee schedule,,,12.56,,,fee schedule,,,12.31,,,fee schedule,,,14.14,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,14.14,,,fee schedule,,,14.14,,,fee schedule,,,10.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET AG IA IMM ENZ FUNGITELL,3123817,CDM,306,RC,87449,CPT,,,,,,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET AG IA IMM ENZ FUNGITELL,3123817,CDM,306,RC,87449,CPT,,,,,,outpatient,facility,,,97,40.74,10.43,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,11.98,,,fee schedule,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,12.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",87.3,,,percent of total billed charges,,,11.98,,,fee schedule,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,17.37,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.17,,,fee schedule,,,10.64,,,fee schedule,,,10.64,,,fee schedule,,,10.43,,,fee schedule,,,11.98,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,11.98,,,fee schedule,,,11.98,,,fee schedule,,,14.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SUSCPT MIC PLATE EA LSI NS,3123825,CDM,300,RC,87186,CPT,,,,,,inpatient,facility,,,200,84,170,192,,170,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174,,,percent of total billed charges,,,,,,,,,180,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SUSCPT MIC PLATE EA LSI NS,3123825,CDM,300,RC,87186,CPT,,,,,,outpatient,facility,,,200,84,7.53,192,,170,,,percent of total billed charges,,,54,,,percent of total billed charges,,,137.6,,,percent of total billed charges,,,134.6,,,percent of total billed charges,,,169,,,percent of total billed charges,,,8.65,,,fee schedule,,,174,,,percent of total billed charges,,,174,,,percent of total billed charges,,,170,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,8.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",180,,,percent of total billed charges,,,8.65,,,fee schedule,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,12.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",11.68,,,fee schedule,,,7.68,,,fee schedule,,,7.68,,,fee schedule,,,7.53,,,fee schedule,,,8.65,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",156.2,,,percent of total billed charges,,,182,,,percent of total billed charges,,,8.65,,,fee schedule,,,8.65,,,fee schedule,,,10.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANTI CD19 CAR T CELL,3123833,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,500,210,425,480,,425,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,435,,,percent of total billed charges,,,,,,,,,450,,,percent of total billed charges,,,480,,,percent of total billed charges,,,475,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,465,,,percent of total billed charges,,,475,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANTI CD19 CAR T CELL,3123833,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,500,210,16.22,480,,425,,,percent of total billed charges,,,135,,,percent of total billed charges,,,344,,,percent of total billed charges,,,336.5,,,percent of total billed charges,,,422.5,,,percent of total billed charges,,,18.64,,,fee schedule,,,435,,,percent of total billed charges,,,435,,,percent of total billed charges,,,425,,,percent of total billed charges,,,480,,,percent of total billed charges,,,475,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",450,,,percent of total billed charges,,,18.64,,,fee schedule,,,465,,,percent of total billed charges,,,475,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",390.5,,,percent of total billed charges,,,455,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DIS INFCT SARS COV 2 TGT 21,3123874,CDM,310,RC,0225U,CPT,,,,,,inpatient,facility,,,1251,525.42,1063.35,1200.96,,1063.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1088.37,,,percent of total billed charges,,,,,,,,,1125.9,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DIS INFCT SARS COV 2 TGT 21,3123874,CDM,310,RC,0225U,CPT,,,,,,outpatient,facility,,,1251,525.42,337.77,1200.96,,1063.35,,,percent of total billed charges,,,337.77,,,percent of total billed charges,,,860.69,,,percent of total billed charges,,,841.92,,,percent of total billed charges,,,1057.1,,,percent of total billed charges,,,416.78,,,fee schedule,,,1088.37,,,percent of total billed charges,,,1088.37,,,percent of total billed charges,,,1063.35,,,percent of total billed charges,,,1200.96,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,425.12,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1125.9,,,percent of total billed charges,,,416.78,,,fee schedule,,,1163.43,,,percent of total billed charges,,,1188.45,,,percent of total billed charges,,,604.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",562.65,,,fee schedule,,,370.1,,,fee schedule,,,370.1,,,fee schedule,,,362.7,,,fee schedule,,,416.78,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",977.03,,,percent of total billed charges,,,1138.41,,,percent of total billed charges,,,416.78,,,fee schedule,,,416.78,,,fee schedule,,,,,,,,
POC FERN,3123882,CDM,301,RC,Q0114,HCPCS,,,,,,inpatient,facility,,,66,27.72,56.1,63.36,,56.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.42,,,percent of total billed charges,,,,,,,,,59.4,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
POC FERN,3123882,CDM,301,RC,Q0114,HCPCS,,,,,,outpatient,facility,,,66,27.72,8.47,63.36,,56.1,,,percent of total billed charges,,,17.82,,,percent of total billed charges,,,45.41,,,percent of total billed charges,,,44.42,,,percent of total billed charges,,,55.77,,,percent of total billed charges,,,9.74,,,fee schedule,,,57.42,,,percent of total billed charges,,,57.42,,,percent of total billed charges,,,56.1,,,percent of total billed charges,,,63.36,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,9.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",59.4,,,percent of total billed charges,,,9.74,,,fee schedule,,,61.38,,,percent of total billed charges,,,62.7,,,percent of total billed charges,,,14.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",13.15,,,fee schedule,,,8.65,,,fee schedule,,,8.65,,,fee schedule,,,8.48,,,fee schedule,,,9.74,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",51.55,,,percent of total billed charges,,,60.06,,,percent of total billed charges,,,9.74,,,fee schedule,,,9.74,,,fee schedule,,,8.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM AB BP230 QN,3123981,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM AB BP230 QN,3123981,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,90,37.8,15.03,86.4,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,17.27,,,fee schedule,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",81,,,percent of total billed charges,,,17.27,,,fee schedule,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA LEPTOSPIRA PCR PRB AMP,3124021,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA LEPTOSPIRA PCR PRB AMP,3124021,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANLY MUTATION KRAS,3124054,CDM,310,RC,81479,CPT,,,,,,inpatient,facility,,,190,79.8,161.5,182.4,,161.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,165.3,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANLY MUTATION KRAS,3124054,CDM,310,RC,81479,CPT,,,,,,outpatient,facility,,,190,79.8,51.3,190,,161.5,,,percent of total billed charges,,,51.3,,,percent of total billed charges,,,130.72,,,percent of total billed charges,,,127.87,,,percent of total billed charges,,,160.55,,,percent of total billed charges,,,,,,,,,165.3,,,percent of total billed charges,,,165.3,,,percent of total billed charges,,,161.5,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,171,,,percent of total billed charges,,,,,,,,,176.7,,,percent of total billed charges,,,180.5,,,percent of total billed charges,,,,,,,,,,,,,,,190,,,fee schedule,,,190,,,fee schedule,,,186.2,,,fee schedule,,,,,,,,,148.39,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,133,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANLY MUTATION NRAS,3124062,CDM,310,RC,81479,CPT,,,,,,inpatient,facility,,,659,276.78,560.15,632.64,,560.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,573.33,,,percent of total billed charges,,,,,,,,,593.1,,,percent of total billed charges,,,632.64,,,percent of total billed charges,,,626.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,612.87,,,percent of total billed charges,,,626.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANLY MUTATION NRAS,3124062,CDM,310,RC,81479,CPT,,,,,,outpatient,facility,,,659,276.78,177.93,659,,560.15,,,percent of total billed charges,,,177.93,,,percent of total billed charges,,,453.39,,,percent of total billed charges,,,443.51,,,percent of total billed charges,,,556.86,,,percent of total billed charges,,,,,,,,,573.33,,,percent of total billed charges,,,573.33,,,percent of total billed charges,,,560.15,,,percent of total billed charges,,,632.64,,,percent of total billed charges,,,626.05,,,percent of total billed charges,,,,,,,,,593.1,,,percent of total billed charges,,,,,,,,,612.87,,,percent of total billed charges,,,626.05,,,percent of total billed charges,,,,,,,,,,,,,,,659,,,fee schedule,,,659,,,fee schedule,,,645.82,,,fee schedule,,,,,,,,,514.68,,,percent of total billed charges,,,599.69,,,percent of total billed charges,,,,,,,,,,,,,,,461.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB ANLY TRANSLOCATION NTRK,3124070,CDM,310,RC,81194,CPT,,,,,,inpatient,facility,,,1555,653.1,1321.75,1492.8,,1321.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1352.85,,,percent of total billed charges,,,,,,,,,1399.5,,,percent of total billed charges,,,1492.8,,,percent of total billed charges,,,1477.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1446.15,,,percent of total billed charges,,,1477.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB ANLY TRANSLOCATION NTRK,3124070,CDM,310,RC,81194,CPT,,,,,,outpatient,facility,,,1555,653.1,419.85,1555,,1321.75,,,percent of total billed charges,,,419.85,,,percent of total billed charges,,,1069.84,,,percent of total billed charges,,,1046.51,,,percent of total billed charges,,,1313.97,,,percent of total billed charges,,,518.28,,,fee schedule,,,1352.85,,,percent of total billed charges,,,1352.85,,,percent of total billed charges,,,1321.75,,,percent of total billed charges,,,1492.8,,,percent of total billed charges,,,1477.25,,,percent of total billed charges,,,528.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1399.5,,,percent of total billed charges,,,518.28,,,fee schedule,,,1446.15,,,percent of total billed charges,,,1477.25,,,percent of total billed charges,,,751.51,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",699.68,,,fee schedule,,,1555,,,fee schedule,,,1555,,,fee schedule,,,1555,,,fee schedule,,,518.28,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1214.45,,,percent of total billed charges,,,1415.05,,,percent of total billed charges,,,518.28,,,fee schedule,,,518.28,,,fee schedule,,,,,,,,
LAB HCV INFCT DIS CHRNC 6 ASSAYS NS,3124229,CDM,310,RC,81596,CPT,,,,,,inpatient,facility,,,217,91.14,184.45,208.32,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.79,,,percent of total billed charges,,,,,,,,,195.3,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB HCV INFCT DIS CHRNC 6 ASSAYS NS,3124229,CDM,310,RC,81596,CPT,,,,,,outpatient,facility,,,217,91.14,58.59,217,,184.45,,,percent of total billed charges,,,58.59,,,percent of total billed charges,,,149.3,,,percent of total billed charges,,,146.04,,,percent of total billed charges,,,183.36,,,percent of total billed charges,,,72.19,,,fee schedule,,,188.79,,,percent of total billed charges,,,188.79,,,percent of total billed charges,,,184.45,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,73.63,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",195.3,,,percent of total billed charges,,,72.19,,,fee schedule,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,104.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.46,,,fee schedule,,,217,,,fee schedule,,,217,,,fee schedule,,,217,,,fee schedule,,,72.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",169.48,,,percent of total billed charges,,,197.47,,,percent of total billed charges,,,72.19,,,fee schedule,,,72.19,,,fee schedule,,,63.35,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB NORTRIPTYLINE,3124252,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,68,28.56,57.8,65.28,,57.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,59.16,,,percent of total billed charges,,,,,,,,,61.2,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB NORTRIPTYLINE,3124252,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,68,28.56,16.22,65.28,,57.8,,,percent of total billed charges,,,18.36,,,percent of total billed charges,,,46.78,,,percent of total billed charges,,,45.76,,,percent of total billed charges,,,57.46,,,percent of total billed charges,,,18.64,,,fee schedule,,,59.16,,,percent of total billed charges,,,59.16,,,percent of total billed charges,,,57.8,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",61.2,,,percent of total billed charges,,,18.64,,,fee schedule,,,63.24,,,percent of total billed charges,,,64.6,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",53.11,,,percent of total billed charges,,,61.88,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB IMM INHIBIN B QN,3124286,CDM,301,RC,83520,CPT,,,,,,inpatient,facility,,,104,43.68,88.4,99.84,,88.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,90.48,,,percent of total billed charges,,,,,,,,,93.6,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB IMM INHIBIN B QN,3124286,CDM,301,RC,83520,CPT,,,,,,outpatient,facility,,,104,43.68,15.03,99.84,,88.4,,,percent of total billed charges,,,28.08,,,percent of total billed charges,,,71.55,,,percent of total billed charges,,,69.99,,,percent of total billed charges,,,87.88,,,percent of total billed charges,,,17.27,,,fee schedule,,,90.48,,,percent of total billed charges,,,90.48,,,percent of total billed charges,,,88.4,,,percent of total billed charges,,,99.84,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,17.62,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",93.6,,,percent of total billed charges,,,17.27,,,fee schedule,,,96.72,,,percent of total billed charges,,,98.8,,,percent of total billed charges,,,25.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23.31,,,fee schedule,,,15.34,,,fee schedule,,,15.34,,,fee schedule,,,15.03,,,fee schedule,,,17.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",81.22,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,17.27,,,fee schedule,,,17.27,,,fee schedule,,,15.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR AB MOG TITER,3124294,CDM,302,RC,86362,CPT,,,,,,inpatient,facility,,,837,351.54,711.45,803.52,,711.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728.19,,,percent of total billed charges,,,,,,,,,753.3,,,percent of total billed charges,,,803.52,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,778.41,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR AB MOG TITER,3124294,CDM,302,RC,86362,CPT,,,,,,outpatient,facility,,,837,351.54,10.49,803.52,,711.45,,,percent of total billed charges,,,225.99,,,percent of total billed charges,,,575.86,,,percent of total billed charges,,,563.3,,,percent of total billed charges,,,707.26,,,percent of total billed charges,,,12.05,,,fee schedule,,,728.19,,,percent of total billed charges,,,728.19,,,percent of total billed charges,,,711.45,,,percent of total billed charges,,,803.52,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",753.3,,,percent of total billed charges,,,12.05,,,fee schedule,,,778.41,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",653.7,,,percent of total billed charges,,,761.67,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,12.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB SCR ANCA TITER AB EA,3124302,CDM,302,RC,86037,CPT,,,,,,inpatient,facility,,,62,26.04,52.7,59.52,,52.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53.94,,,percent of total billed charges,,,,,,,,,55.8,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB SCR ANCA TITER AB EA,3124302,CDM,302,RC,86037,CPT,,,,,,outpatient,facility,,,62,26.04,10.49,59.52,,52.7,,,percent of total billed charges,,,16.74,,,percent of total billed charges,,,42.66,,,percent of total billed charges,,,41.73,,,percent of total billed charges,,,52.39,,,percent of total billed charges,,,12.05,,,fee schedule,,,53.94,,,percent of total billed charges,,,53.94,,,percent of total billed charges,,,52.7,,,percent of total billed charges,,,59.52,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,12.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",55.8,,,percent of total billed charges,,,12.05,,,fee schedule,,,57.66,,,percent of total billed charges,,,58.9,,,percent of total billed charges,,,17.47,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",16.27,,,fee schedule,,,10.7,,,fee schedule,,,10.7,,,fee schedule,,,10.49,,,fee schedule,,,12.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",48.42,,,percent of total billed charges,,,56.42,,,percent of total billed charges,,,12.05,,,fee schedule,,,12.05,,,fee schedule,,,,,,,,
LAB CHROMAT MS BETA AMYLOID RATIO,3124484,CDM,301,RC,82542,CPT,,,,,,inpatient,facility,,,1409,591.78,1197.65,1352.64,,1197.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1225.83,,,percent of total billed charges,,,,,,,,,1268.1,,,percent of total billed charges,,,1352.64,,,percent of total billed charges,,,1338.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1310.37,,,percent of total billed charges,,,1338.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CHROMAT MS BETA AMYLOID RATIO,3124484,CDM,301,RC,82542,CPT,,,,,,outpatient,facility,,,1409,591.78,14.06,1352.64,,1197.65,,,percent of total billed charges,,,380.43,,,percent of total billed charges,,,969.39,,,percent of total billed charges,,,948.26,,,percent of total billed charges,,,1190.61,,,percent of total billed charges,,,24.09,,,fee schedule,,,1225.83,,,percent of total billed charges,,,1225.83,,,percent of total billed charges,,,1197.65,,,percent of total billed charges,,,1352.64,,,percent of total billed charges,,,1338.55,,,percent of total billed charges,,,24.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1268.1,,,percent of total billed charges,,,24.09,,,fee schedule,,,1310.37,,,percent of total billed charges,,,1338.55,,,percent of total billed charges,,,34.93,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",32.52,,,fee schedule,,,21.39,,,fee schedule,,,21.39,,,fee schedule,,,20.96,,,fee schedule,,,24.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1100.43,,,percent of total billed charges,,,1282.19,,,percent of total billed charges,,,24.09,,,fee schedule,,,24.09,,,fee schedule,,,14.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA RUBELLA PCR PRB AMP,3124492,CDM,306,RC,87798,CPT,,,,,,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA RUBELLA PCR PRB AMP,3124492,CDM,306,RC,87798,CPT,,,,,,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,35.09,,,fee schedule,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,35.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",95.4,,,percent of total billed charges,,,35.09,,,fee schedule,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,50.88,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",47.37,,,fee schedule,,,31.16,,,fee schedule,,,31.16,,,fee schedule,,,30.54,,,fee schedule,,,35.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,35.09,,,fee schedule,,,35.09,,,fee schedule,,,43.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB RBC DNA HEA 35 AG 11 BLD GRP NS,3124518,CDM,302,RC,0001U,CPT,,,,,,inpatient,facility,,,2160,907.2,1836,2073.6,,1836,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1879.2,,,percent of total billed charges,,,,,,,,,1944,,,percent of total billed charges,,,2073.6,,,percent of total billed charges,,,2052,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2008.8,,,percent of total billed charges,,,2052,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB RBC DNA HEA 35 AG 11 BLD GRP NS,3124518,CDM,302,RC,0001U,CPT,,,,,,outpatient,facility,,,2160,907.2,583.2,2073.6,,1836,,,percent of total billed charges,,,583.2,,,percent of total billed charges,,,1486.08,,,percent of total billed charges,,,1453.68,,,percent of total billed charges,,,1825.2,,,percent of total billed charges,,,720,,,fee schedule,,,1879.2,,,percent of total billed charges,,,1879.2,,,percent of total billed charges,,,1836,,,percent of total billed charges,,,2073.6,,,percent of total billed charges,,,2052,,,percent of total billed charges,,,734.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1944,,,percent of total billed charges,,,720,,,fee schedule,,,2008.8,,,percent of total billed charges,,,2052,,,percent of total billed charges,,,1044,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",972,,,fee schedule,,,639.36,,,fee schedule,,,639.36,,,fee schedule,,,626.57,,,fee schedule,,,720,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1686.96,,,percent of total billed charges,,,1965.6,,,percent of total billed charges,,,720,,,fee schedule,,,720,,,fee schedule,,,,,,,,
LAB DET IA ENTEROBACTR MULT PRB AMP,3124542,CDM,306,RC,87801,CPT,,,,,,inpatient,facility,,,454,190.68,385.9,435.84,,385.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,394.98,,,percent of total billed charges,,,,,,,,,408.6,,,percent of total billed charges,,,435.84,,,percent of total billed charges,,,431.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,422.22,,,percent of total billed charges,,,431.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA ENTEROBACTR MULT PRB AMP,3124542,CDM,306,RC,87801,CPT,,,,,,outpatient,facility,,,454,190.68,61.09,435.84,,385.9,,,percent of total billed charges,,,122.58,,,percent of total billed charges,,,312.35,,,percent of total billed charges,,,305.54,,,percent of total billed charges,,,383.63,,,percent of total billed charges,,,70.2,,,fee schedule,,,394.98,,,percent of total billed charges,,,394.98,,,percent of total billed charges,,,385.9,,,percent of total billed charges,,,435.84,,,percent of total billed charges,,,431.3,,,percent of total billed charges,,,71.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.6,,,percent of total billed charges,,,70.2,,,fee schedule,,,422.22,,,percent of total billed charges,,,431.3,,,percent of total billed charges,,,101.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",94.77,,,fee schedule,,,62.34,,,fee schedule,,,62.34,,,fee schedule,,,61.09,,,fee schedule,,,70.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",354.57,,,percent of total billed charges,,,413.14,,,percent of total billed charges,,,70.2,,,fee schedule,,,70.2,,,fee schedule,,,86.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB DET IA BACTERIAL MULT PRB AMP,3124559,CDM,306,RC,87801,CPT,,,,,,inpatient,facility,,,1309,549.78,1112.65,1256.64,,1112.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.83,,,percent of total billed charges,,,,,,,,,1178.1,,,percent of total billed charges,,,1256.64,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1217.37,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB DET IA BACTERIAL MULT PRB AMP,3124559,CDM,306,RC,87801,CPT,,,,,,outpatient,facility,,,1309,549.78,61.09,1256.64,,1112.65,,,percent of total billed charges,,,353.43,,,percent of total billed charges,,,900.59,,,percent of total billed charges,,,880.96,,,percent of total billed charges,,,1106.11,,,percent of total billed charges,,,70.2,,,fee schedule,,,1138.83,,,percent of total billed charges,,,1138.83,,,percent of total billed charges,,,1112.65,,,percent of total billed charges,,,1256.64,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,71.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1178.1,,,percent of total billed charges,,,70.2,,,fee schedule,,,1217.37,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,101.79,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",94.77,,,fee schedule,,,62.34,,,fee schedule,,,62.34,,,fee schedule,,,61.09,,,fee schedule,,,70.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",1022.33,,,percent of total billed charges,,,1191.19,,,percent of total billed charges,,,70.2,,,fee schedule,,,70.2,,,fee schedule,,,86.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB CLONAZEPAM,3124567,CDM,301,RC,80299,CPT,,,,,,inpatient,facility,,,67,28.14,56.95,64.32,,56.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,58.29,,,percent of total billed charges,,,,,,,,,60.3,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB CLONAZEPAM,3124567,CDM,301,RC,80299,CPT,,,,,,outpatient,facility,,,67,28.14,16.22,64.32,,56.95,,,percent of total billed charges,,,18.09,,,percent of total billed charges,,,46.1,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,56.61,,,percent of total billed charges,,,18.64,,,fee schedule,,,58.29,,,percent of total billed charges,,,58.29,,,percent of total billed charges,,,56.95,,,percent of total billed charges,,,64.32,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,19.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",60.3,,,percent of total billed charges,,,18.64,,,fee schedule,,,62.31,,,percent of total billed charges,,,63.65,,,percent of total billed charges,,,27.03,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",25.16,,,fee schedule,,,16.55,,,fee schedule,,,16.55,,,fee schedule,,,16.22,,,fee schedule,,,18.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",52.33,,,percent of total billed charges,,,60.97,,,percent of total billed charges,,,18.64,,,fee schedule,,,18.64,,,fee schedule,,,16.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE B CELL CLONALITY PCR,3124583,CDM,301,RC,84999,CPT,,,,,,inpatient,facility,,,51,21.42,43.35,48.96,,43.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44.37,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE B CELL CLONALITY PCR,3124583,CDM,301,RC,84999,CPT,,,,,,outpatient,facility,,,51,21.42,13.77,51,,43.35,,,percent of total billed charges,,,13.77,,,percent of total billed charges,,,35.09,,,percent of total billed charges,,,34.32,,,percent of total billed charges,,,43.09,,,percent of total billed charges,,,,,,,,,44.37,,,percent of total billed charges,,,44.37,,,percent of total billed charges,,,43.35,,,percent of total billed charges,,,48.96,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,45.9,,,percent of total billed charges,,,,,,,,,47.43,,,percent of total billed charges,,,48.45,,,percent of total billed charges,,,,,,,,,,,,,,,51,,,fee schedule,,,51,,,fee schedule,,,49.98,,,fee schedule,,,,,,,,,39.83,,,percent of total billed charges,,,46.41,,,percent of total billed charges,,,,,,,,,,,,,,,29.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
LAB GENE HFE VAR COMMON,3124625,CDM,310,RC,81256,CPT,,,,,,inpatient,facility,,,197,82.74,167.45,189.12,,167.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,171.39,,,percent of total billed charges,,,,,,,,,177.3,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
LAB GENE HFE VAR COMMON,3124625,CDM,310,RC,81256,CPT,,,,,,outpatient,facility,,,197,82.74,53.19,197,,167.45,,,percent of total billed charges,,,53.19,,,percent of total billed charges,,,135.54,,,percent of total billed charges,,,132.58,,,percent of total billed charges,,,166.47,,,percent of total billed charges,,,65.36,,,fee schedule,,,171.39,,,percent of total billed charges,,,171.39,,,percent of total billed charges,,,167.45,,,percent of total billed charges,,,189.12,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,66.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",177.3,,,percent of total billed charges,,,65.36,,,fee schedule,,,183.21,,,percent of total billed charges,,,187.15,,,percent of total billed charges,,,94.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",88.24,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,197,,,fee schedule,,,65.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",153.86,,,percent of total billed charges,,,179.27,,,percent of total billed charges,,,65.36,,,fee schedule,,,65.36,,,fee schedule,,,,,,,,
INJ ANES PLEXUS HYPOGASTRIC,3200995,CDM,361,RC,64517,CPT,,,,,,inpatient,facility,,,2519,1057.98,2141.15,2418.24,,2141.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2191.53,,,percent of total billed charges,,,,,,,,,2267.1,,,percent of total billed charges,,,2418.24,,,percent of total billed charges,,,2393.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2342.67,,,percent of total billed charges,,,2393.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ANES PLEXUS HYPOGASTRIC,3200995,CDM,361,RC,64517,CPT,,,,,,outpatient,facility,,,2519,1057.98,680.13,3522,,2141.15,,,percent of total billed charges,,,680.13,,,percent of total billed charges,,,1733.07,,,percent of total billed charges,,,1695.29,,,percent of total billed charges,,,2128.55,,,percent of total billed charges,,,,,,,,,2191.53,,,percent of total billed charges,,,2191.53,,,percent of total billed charges,,,2141.15,,,percent of total billed charges,,,2418.24,,,percent of total billed charges,,,2393.05,,,percent of total billed charges,,,,,,,,,2267.1,,,percent of total billed charges,,,,,,,,,2342.67,,,percent of total billed charges,,,2393.05,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2292.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ANES PLEXUS HYPOGASTRIC,3200995,CDM,361,RC,64517,CPT,5443,APC,,,,outpatient,facility,,,2519,2519,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM CALCULI BILI DUCT AND GALLBLDR S ANDI,3202140,CDM,361,RC,47544,CPT,,,,,,inpatient,facility,,,5625,2362.5,4781.25,5400,,4781.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4893.75,,,percent of total billed charges,,,,,,,,,5062.5,,,percent of total billed charges,,,5400,,,percent of total billed charges,,,5343.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5231.25,,,percent of total billed charges,,,5343.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM CALCULI BILI DUCT AND GALLBLDR S ANDI,3202140,CDM,361,RC,47544,CPT,,,,,,outpatient,facility,,,5625,2362.5,1518.75,5625,,4781.25,,,percent of total billed charges,,,1518.75,,,percent of total billed charges,,,3870,,,percent of total billed charges,,,3785.62,,,percent of total billed charges,,,4753.13,,,percent of total billed charges,,,,,,,,,4893.75,,,percent of total billed charges,,,4893.75,,,percent of total billed charges,,,4781.25,,,percent of total billed charges,,,5400,,,percent of total billed charges,,,5343.75,,,percent of total billed charges,,,,,,,,,5062.5,,,percent of total billed charges,,,,,,,,,5231.25,,,percent of total billed charges,,,5343.75,,,percent of total billed charges,,,,,,,,,,,,,,,5625,,,fee schedule,,,5625,,,fee schedule,,,5625,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,5118.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC NEW RT S ANDI,3202546,CDM,361,RC,50430,CPT,,,,,RT  ,inpatient,facility,,,3660,1537.2,3111,3513.6,,3111,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3184.2,,,percent of total billed charges,,,,,,,,,3294,,,percent of total billed charges,,,3513.6,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3403.8,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC NEW RT S ANDI,3202546,CDM,361,RC,50430,CPT,,,,,RT  ,outpatient,facility,,,3660,1537.2,683.13,3522,,3111,,,percent of total billed charges,,,988.2,,,percent of total billed charges,,,2518.08,,,percent of total billed charges,,,2463.18,,,percent of total billed charges,,,3092.7,,,percent of total billed charges,,,,,,,,,3184.2,,,percent of total billed charges,,,3184.2,,,percent of total billed charges,,,3111,,,percent of total billed charges,,,3513.6,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,3294,,,percent of total billed charges,,,,,,,,,3403.8,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,3330.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC NEW RT S ANDI,3202546,CDM,361,RC,50430,CPT,5372,APC,,,RT  ,outpatient,facility,,,3660,3660,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ NEPH AND URETERGRM ACC NEW LT S ANDI,3202553,CDM,361,RC,50430,CPT,,,,,LT  ,inpatient,facility,,,3660,1537.2,3111,3513.6,,3111,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3184.2,,,percent of total billed charges,,,,,,,,,3294,,,percent of total billed charges,,,3513.6,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3403.8,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC NEW LT S ANDI,3202553,CDM,361,RC,50430,CPT,,,,,LT  ,outpatient,facility,,,3660,1537.2,683.13,3522,,3111,,,percent of total billed charges,,,988.2,,,percent of total billed charges,,,2518.08,,,percent of total billed charges,,,2463.18,,,percent of total billed charges,,,3092.7,,,percent of total billed charges,,,,,,,,,3184.2,,,percent of total billed charges,,,3184.2,,,percent of total billed charges,,,3111,,,percent of total billed charges,,,3513.6,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,3294,,,percent of total billed charges,,,,,,,,,3403.8,,,percent of total billed charges,,,3477,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,3330.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC NEW LT S ANDI,3202553,CDM,361,RC,50430,CPT,5372,APC,,,LT  ,outpatient,facility,,,3660,3660,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ NEPH AND URETERGRM ACC NEW BI S ANDI,3202561,CDM,361,RC,50430,CPT,,,,,50,inpatient,facility,,,5490,2305.8,4666.5,5270.4,,4666.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4776.3,,,percent of total billed charges,,,,,,,,,4941,,,percent of total billed charges,,,5270.4,,,percent of total billed charges,,,5215.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5105.7,,,percent of total billed charges,,,5215.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC NEW BI S ANDI,3202561,CDM,361,RC,50430,CPT,,,,,50,outpatient,facility,,,5490,2305.8,683.13,5270.4,,4666.5,,,percent of total billed charges,,,1482.3,,,percent of total billed charges,,,3777.12,,,percent of total billed charges,,,3694.77,,,percent of total billed charges,,,4639.05,,,percent of total billed charges,,,,,,,,,4776.3,,,percent of total billed charges,,,4776.3,,,percent of total billed charges,,,4666.5,,,percent of total billed charges,,,5270.4,,,percent of total billed charges,,,5215.5,,,percent of total billed charges,,,,,,,,,4941,,,percent of total billed charges,,,,,,,,,5105.7,,,percent of total billed charges,,,5215.5,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,4995.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC NEW BI S ANDI,3202561,CDM,361,RC,50430,CPT,5372,APC,,,50,outpatient,facility,,,5490,5490,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ NEPH AND URETERGRM ACC EXST RT S ANDI,3202728,CDM,361,RC,50431,CPT,,,,,RT  ,inpatient,facility,,,1565,657.3,1330.25,1502.4,,1330.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1361.55,,,percent of total billed charges,,,,,,,,,1408.5,,,percent of total billed charges,,,1502.4,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1455.45,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC EXST RT S ANDI,3202728,CDM,361,RC,50431,CPT,,,,,RT  ,outpatient,facility,,,1565,657.3,422.55,3522,,1330.25,,,percent of total billed charges,,,422.55,,,percent of total billed charges,,,1076.72,,,percent of total billed charges,,,1053.24,,,percent of total billed charges,,,1322.42,,,percent of total billed charges,,,,,,,,,1361.55,,,percent of total billed charges,,,1361.55,,,percent of total billed charges,,,1330.25,,,percent of total billed charges,,,1502.4,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,1408.5,,,percent of total billed charges,,,,,,,,,1455.45,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1424.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC EXST RT S ANDI,3202728,CDM,361,RC,50431,CPT,5372,APC,,,RT  ,outpatient,facility,,,1565,1565,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ NEPH AND URETERGRM ACC EXST LT S ANDI,3202736,CDM,361,RC,50431,CPT,,,,,LT  ,inpatient,facility,,,1565,657.3,1330.25,1502.4,,1330.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1361.55,,,percent of total billed charges,,,,,,,,,1408.5,,,percent of total billed charges,,,1502.4,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1455.45,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC EXST LT S ANDI,3202736,CDM,361,RC,50431,CPT,,,,,LT  ,outpatient,facility,,,1565,657.3,422.55,3522,,1330.25,,,percent of total billed charges,,,422.55,,,percent of total billed charges,,,1076.72,,,percent of total billed charges,,,1053.24,,,percent of total billed charges,,,1322.42,,,percent of total billed charges,,,,,,,,,1361.55,,,percent of total billed charges,,,1361.55,,,percent of total billed charges,,,1330.25,,,percent of total billed charges,,,1502.4,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,1408.5,,,percent of total billed charges,,,,,,,,,1455.45,,,percent of total billed charges,,,1486.75,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1424.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC EXST LT S ANDI,3202736,CDM,361,RC,50431,CPT,5372,APC,,,LT  ,outpatient,facility,,,1565,1565,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ NEPH AND URETERGRM ACC EXST BI S ANDI,3202744,CDM,361,RC,50431,CPT,,,,,50,inpatient,facility,,,2347,985.74,1994.95,2253.12,,1994.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2041.89,,,percent of total billed charges,,,,,,,,,2112.3,,,percent of total billed charges,,,2253.12,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2182.71,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC EXST BI S ANDI,3202744,CDM,361,RC,50431,CPT,,,,,50,outpatient,facility,,,2347,985.74,633.69,3522,,1994.95,,,percent of total billed charges,,,633.69,,,percent of total billed charges,,,1614.74,,,percent of total billed charges,,,1579.53,,,percent of total billed charges,,,1983.21,,,percent of total billed charges,,,,,,,,,2041.89,,,percent of total billed charges,,,2041.89,,,percent of total billed charges,,,1994.95,,,percent of total billed charges,,,2253.12,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,2112.3,,,percent of total billed charges,,,,,,,,,2182.71,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2135.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ NEPH AND URETERGRM ACC EXST BI S ANDI,3202744,CDM,361,RC,50431,CPT,5372,APC,,,50,outpatient,facility,,,2347,2347,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INSTILL AGENT FIBRIN TB CTH 1ST DAY,3202751,CDM,361,RC,32561,CPT,,,,,,inpatient,facility,,,1519,637.98,1291.15,1458.24,,1291.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1321.53,,,percent of total billed charges,,,,,,,,,1367.1,,,percent of total billed charges,,,1458.24,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1412.67,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTILL AGENT FIBRIN TB CTH 1ST DAY,3202751,CDM,361,RC,32561,CPT,,,,,,outpatient,facility,,,1519,637.98,410.13,3522,,1291.15,,,percent of total billed charges,,,410.13,,,percent of total billed charges,,,1045.07,,,percent of total billed charges,,,1022.29,,,percent of total billed charges,,,1283.56,,,percent of total billed charges,,,,,,,,,1321.53,,,percent of total billed charges,,,1321.53,,,percent of total billed charges,,,1291.15,,,percent of total billed charges,,,1458.24,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,1367.1,,,percent of total billed charges,,,,,,,,,1412.67,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1382.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTILL AGENT FIBRIN TB CTH 1ST DAY,3202751,CDM,361,RC,32561,CPT,5181,APC,,,,outpatient,facility,,,1519,1519,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH NEPHROSTOMY PERC RT S ANDI,3202876,CDM,361,RC,50432,CPT,,,,,RT  ,inpatient,facility,,,4721,1982.82,4012.85,4532.16,,4012.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4107.27,,,percent of total billed charges,,,,,,,,,4248.9,,,percent of total billed charges,,,4532.16,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4390.53,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROSTOMY PERC RT S ANDI,3202876,CDM,361,RC,50432,CPT,,,,,RT  ,outpatient,facility,,,4721,1982.82,1274.67,11510,,4012.85,,,percent of total billed charges,,,1274.67,,,percent of total billed charges,,,3248.05,,,percent of total billed charges,,,3177.23,,,percent of total billed charges,,,3989.24,,,percent of total billed charges,,,,,,,,,4107.27,,,percent of total billed charges,,,4107.27,,,percent of total billed charges,,,4012.85,,,percent of total billed charges,,,4532.16,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,4248.9,,,percent of total billed charges,,,,,,,,,4390.53,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,4296.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROSTOMY PERC RT S ANDI,3202876,CDM,361,RC,50432,CPT,5373,APC,,,RT  ,outpatient,facility,,,4721,4721,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH NEPHROSTOMY PERC LT S ANDI,3202884,CDM,361,RC,50432,CPT,,,,,LT  ,inpatient,facility,,,4721,1982.82,4012.85,4532.16,,4012.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4107.27,,,percent of total billed charges,,,,,,,,,4248.9,,,percent of total billed charges,,,4532.16,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4390.53,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROSTOMY PERC LT S ANDI,3202884,CDM,361,RC,50432,CPT,,,,,LT  ,outpatient,facility,,,4721,1982.82,1274.67,11510,,4012.85,,,percent of total billed charges,,,1274.67,,,percent of total billed charges,,,3248.05,,,percent of total billed charges,,,3177.23,,,percent of total billed charges,,,3989.24,,,percent of total billed charges,,,,,,,,,4107.27,,,percent of total billed charges,,,4107.27,,,percent of total billed charges,,,4012.85,,,percent of total billed charges,,,4532.16,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,4248.9,,,percent of total billed charges,,,,,,,,,4390.53,,,percent of total billed charges,,,4484.95,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,4296.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROSTOMY PERC LT S ANDI,3202884,CDM,361,RC,50432,CPT,5373,APC,,,LT  ,outpatient,facility,,,4721,4721,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH NEPHROSTOMY PERC BI S ANDI,3202892,CDM,361,RC,50432,CPT,,,,,50,inpatient,facility,,,7081,2974.02,6018.85,6797.76,,6018.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6160.47,,,percent of total billed charges,,,,,,,,,6372.9,,,percent of total billed charges,,,6797.76,,,percent of total billed charges,,,6726.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6585.33,,,percent of total billed charges,,,6726.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROSTOMY PERC BI S ANDI,3202892,CDM,361,RC,50432,CPT,,,,,50,outpatient,facility,,,7081,2974.02,1911.87,11510,,6018.85,,,percent of total billed charges,,,1911.87,,,percent of total billed charges,,,4871.73,,,percent of total billed charges,,,4765.51,,,percent of total billed charges,,,5983.44,,,percent of total billed charges,,,,,,,,,6160.47,,,percent of total billed charges,,,6160.47,,,percent of total billed charges,,,6018.85,,,percent of total billed charges,,,6797.76,,,percent of total billed charges,,,6726.95,,,percent of total billed charges,,,,,,,,,6372.9,,,percent of total billed charges,,,,,,,,,6585.33,,,percent of total billed charges,,,6726.95,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,6443.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROSTOMY PERC BI S ANDI,3202892,CDM,361,RC,50432,CPT,5374,APC,,,50,outpatient,facility,,,7081,7081,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EXCHG CATH NEPH PERC RT S ANDI,3202900,CDM,361,RC,50435,CPT,,,,,RT  ,inpatient,facility,,,2731,1147.02,2321.35,2621.76,,2321.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2375.97,,,percent of total billed charges,,,,,,,,,2457.9,,,percent of total billed charges,,,2621.76,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2539.83,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EXCHG CATH NEPH PERC RT S ANDI,3202900,CDM,361,RC,50435,CPT,,,,,RT  ,outpatient,facility,,,2731,1147.02,737.37,3522,,2321.35,,,percent of total billed charges,,,737.37,,,percent of total billed charges,,,1878.93,,,percent of total billed charges,,,1837.96,,,percent of total billed charges,,,2307.69,,,percent of total billed charges,,,,,,,,,2375.97,,,percent of total billed charges,,,2375.97,,,percent of total billed charges,,,2321.35,,,percent of total billed charges,,,2621.76,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,2457.9,,,percent of total billed charges,,,,,,,,,2539.83,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2485.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EXCHG CATH NEPH PERC RT S ANDI,3202900,CDM,361,RC,50435,CPT,5373,APC,,,RT  ,outpatient,facility,,,2731,2731,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EXCHG CATH NEPH PERC LT S ANDI,3202918,CDM,361,RC,50435,CPT,,,,,LT  ,inpatient,facility,,,2731,1147.02,2321.35,2621.76,,2321.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2375.97,,,percent of total billed charges,,,,,,,,,2457.9,,,percent of total billed charges,,,2621.76,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2539.83,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EXCHG CATH NEPH PERC LT S ANDI,3202918,CDM,361,RC,50435,CPT,,,,,LT  ,outpatient,facility,,,2731,1147.02,737.37,3522,,2321.35,,,percent of total billed charges,,,737.37,,,percent of total billed charges,,,1878.93,,,percent of total billed charges,,,1837.96,,,percent of total billed charges,,,2307.69,,,percent of total billed charges,,,,,,,,,2375.97,,,percent of total billed charges,,,2375.97,,,percent of total billed charges,,,2321.35,,,percent of total billed charges,,,2621.76,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,2457.9,,,percent of total billed charges,,,,,,,,,2539.83,,,percent of total billed charges,,,2594.45,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2485.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EXCHG CATH NEPH PERC LT S ANDI,3202918,CDM,361,RC,50435,CPT,5373,APC,,,LT  ,outpatient,facility,,,2731,2731,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EXCHG CATH NEPH PERC BI S ANDI,3202926,CDM,361,RC,50435,CPT,,,,,50,inpatient,facility,,,4096,1720.32,3481.6,3932.16,,3481.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3563.52,,,percent of total billed charges,,,,,,,,,3686.4,,,percent of total billed charges,,,3932.16,,,percent of total billed charges,,,3891.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3809.28,,,percent of total billed charges,,,3891.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EXCHG CATH NEPH PERC BI S ANDI,3202926,CDM,361,RC,50435,CPT,,,,,50,outpatient,facility,,,4096,1720.32,1105.92,3932.16,,3481.6,,,percent of total billed charges,,,1105.92,,,percent of total billed charges,,,2818.05,,,percent of total billed charges,,,2756.61,,,percent of total billed charges,,,3461.12,,,percent of total billed charges,,,,,,,,,3563.52,,,percent of total billed charges,,,3563.52,,,percent of total billed charges,,,3481.6,,,percent of total billed charges,,,3932.16,,,percent of total billed charges,,,3891.2,,,percent of total billed charges,,,,,,,,,3686.4,,,percent of total billed charges,,,,,,,,,3809.28,,,percent of total billed charges,,,3891.2,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,3727.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EXCHG CATH NEPH PERC BI S ANDI,3202926,CDM,361,RC,50435,CPT,5373,APC,,,50,outpatient,facility,,,4096,4096,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR NEPH PREEXIST RT S ANDI,3203114,CDM,361,RC,50693,CPT,,,,,RT  ,inpatient,facility,,,4072,1710.24,3461.2,3909.12,,3461.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3542.64,,,percent of total billed charges,,,,,,,,,3664.8,,,percent of total billed charges,,,3909.12,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3786.96,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR NEPH PREEXIST RT S ANDI,3203114,CDM,361,RC,50693,CPT,,,,,RT  ,outpatient,facility,,,4072,1710.24,1099.44,15487,,3461.2,,,percent of total billed charges,,,1099.44,,,percent of total billed charges,,,2801.54,,,percent of total billed charges,,,2740.46,,,percent of total billed charges,,,3440.84,,,percent of total billed charges,,,,,,,,,3542.64,,,percent of total billed charges,,,3542.64,,,percent of total billed charges,,,3461.2,,,percent of total billed charges,,,3909.12,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,3664.8,,,percent of total billed charges,,,,,,,,,3786.96,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,3705.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR NEPH PREEXIST RT S ANDI,3203114,CDM,361,RC,50693,CPT,5374,APC,,,RT  ,outpatient,facility,,,4072,4072,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR NEPH PREEXIST LT S ANDI,3203122,CDM,361,RC,50693,CPT,,,,,LT  ,inpatient,facility,,,4072,1710.24,3461.2,3909.12,,3461.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3542.64,,,percent of total billed charges,,,,,,,,,3664.8,,,percent of total billed charges,,,3909.12,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3786.96,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR NEPH PREEXIST LT S ANDI,3203122,CDM,361,RC,50693,CPT,,,,,LT  ,outpatient,facility,,,4072,1710.24,1099.44,15487,,3461.2,,,percent of total billed charges,,,1099.44,,,percent of total billed charges,,,2801.54,,,percent of total billed charges,,,2740.46,,,percent of total billed charges,,,3440.84,,,percent of total billed charges,,,,,,,,,3542.64,,,percent of total billed charges,,,3542.64,,,percent of total billed charges,,,3461.2,,,percent of total billed charges,,,3909.12,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,3664.8,,,percent of total billed charges,,,,,,,,,3786.96,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,3705.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR NEPH PREEXIST LT S ANDI,3203122,CDM,361,RC,50693,CPT,5374,APC,,,LT  ,outpatient,facility,,,4072,4072,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR NEPH PREEXIST BI S ANDI,3203130,CDM,361,RC,50693,CPT,,,,,50,inpatient,facility,,,6108,2565.36,5191.8,5863.68,,5191.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5313.96,,,percent of total billed charges,,,,,,,,,5497.2,,,percent of total billed charges,,,5863.68,,,percent of total billed charges,,,5802.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5680.44,,,percent of total billed charges,,,5802.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR NEPH PREEXIST BI S ANDI,3203130,CDM,361,RC,50693,CPT,,,,,50,outpatient,facility,,,6108,2565.36,1649.16,15487,,5191.8,,,percent of total billed charges,,,1649.16,,,percent of total billed charges,,,4202.3,,,percent of total billed charges,,,4110.68,,,percent of total billed charges,,,5161.26,,,percent of total billed charges,,,,,,,,,5313.96,,,percent of total billed charges,,,5313.96,,,percent of total billed charges,,,5191.8,,,percent of total billed charges,,,5863.68,,,percent of total billed charges,,,5802.6,,,percent of total billed charges,,,,,,,,,5497.2,,,percent of total billed charges,,,,,,,,,5680.44,,,percent of total billed charges,,,5802.6,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,5558.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR NEPH PREEXIST BI S ANDI,3203130,CDM,361,RC,50693,CPT,5374,APC,,,50,outpatient,facility,,,6108,6108,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR WO NEPH CATH RT S ANDI,3203148,CDM,361,RC,50694,CPT,,,,,RT  ,inpatient,facility,,,5335,2240.7,4534.75,5121.6,,4534.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4641.45,,,percent of total billed charges,,,,,,,,,4801.5,,,percent of total billed charges,,,5121.6,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4961.55,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR WO NEPH CATH RT S ANDI,3203148,CDM,361,RC,50694,CPT,,,,,RT  ,outpatient,facility,,,5335,2240.7,1440.45,15487,,4534.75,,,percent of total billed charges,,,1440.45,,,percent of total billed charges,,,3670.48,,,percent of total billed charges,,,3590.45,,,percent of total billed charges,,,4508.07,,,percent of total billed charges,,,,,,,,,4641.45,,,percent of total billed charges,,,4641.45,,,percent of total billed charges,,,4534.75,,,percent of total billed charges,,,5121.6,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,4801.5,,,percent of total billed charges,,,,,,,,,4961.55,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4854.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR WO NEPH CATH RT S ANDI,3203148,CDM,361,RC,50694,CPT,5374,APC,,,RT  ,outpatient,facility,,,5335,5335,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR WO NEPH CATH LT S ANDI,3203155,CDM,361,RC,50694,CPT,,,,,LT  ,inpatient,facility,,,5335,2240.7,4534.75,5121.6,,4534.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4641.45,,,percent of total billed charges,,,,,,,,,4801.5,,,percent of total billed charges,,,5121.6,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4961.55,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR WO NEPH CATH LT S ANDI,3203155,CDM,361,RC,50694,CPT,,,,,LT  ,outpatient,facility,,,5335,2240.7,1440.45,15487,,4534.75,,,percent of total billed charges,,,1440.45,,,percent of total billed charges,,,3670.48,,,percent of total billed charges,,,3590.45,,,percent of total billed charges,,,4508.07,,,percent of total billed charges,,,,,,,,,4641.45,,,percent of total billed charges,,,4641.45,,,percent of total billed charges,,,4534.75,,,percent of total billed charges,,,5121.6,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,4801.5,,,percent of total billed charges,,,,,,,,,4961.55,,,percent of total billed charges,,,5068.25,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4854.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR WO NEPH CATH LT S ANDI,3203155,CDM,361,RC,50694,CPT,5374,APC,,,LT  ,outpatient,facility,,,5335,5335,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR WO NEPH CATH BI S ANDI,3203163,CDM,361,RC,50694,CPT,,,,,50,inpatient,facility,,,8002,3360.84,6801.7,7681.92,,6801.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6961.74,,,percent of total billed charges,,,,,,,,,7201.8,,,percent of total billed charges,,,7681.92,,,percent of total billed charges,,,7601.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7441.86,,,percent of total billed charges,,,7601.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR WO NEPH CATH BI S ANDI,3203163,CDM,361,RC,50694,CPT,,,,,50,outpatient,facility,,,8002,3360.84,2160.54,15487,,6801.7,,,percent of total billed charges,,,2160.54,,,percent of total billed charges,,,5505.38,,,percent of total billed charges,,,5385.35,,,percent of total billed charges,,,6761.69,,,percent of total billed charges,,,,,,,,,6961.74,,,percent of total billed charges,,,6961.74,,,percent of total billed charges,,,6801.7,,,percent of total billed charges,,,7681.92,,,percent of total billed charges,,,7601.9,,,percent of total billed charges,,,,,,,,,7201.8,,,percent of total billed charges,,,,,,,,,7441.86,,,percent of total billed charges,,,7601.9,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,7281.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR WO NEPH CATH BI S ANDI,3203163,CDM,361,RC,50694,CPT,5374,APC,,,50,outpatient,facility,,,8002,8002,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR W NEPH CATH RT S ANDI,3203213,CDM,361,RC,50695,CPT,,,,,RT  ,inpatient,facility,,,6801,2856.42,5780.85,6528.96,,5780.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5916.87,,,percent of total billed charges,,,,,,,,,6120.9,,,percent of total billed charges,,,6528.96,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6324.93,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR W NEPH CATH RT S ANDI,3203213,CDM,361,RC,50695,CPT,,,,,RT  ,outpatient,facility,,,6801,2856.42,1836.27,15487,,5780.85,,,percent of total billed charges,,,1836.27,,,percent of total billed charges,,,4679.09,,,percent of total billed charges,,,4577.07,,,percent of total billed charges,,,5746.85,,,percent of total billed charges,,,,,,,,,5916.87,,,percent of total billed charges,,,5916.87,,,percent of total billed charges,,,5780.85,,,percent of total billed charges,,,6528.96,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,6120.9,,,percent of total billed charges,,,,,,,,,6324.93,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6188.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR W NEPH CATH RT S ANDI,3203213,CDM,361,RC,50695,CPT,5374,APC,,,RT  ,outpatient,facility,,,6801,6801,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR W NEPH CATH LT S ANDI,3203221,CDM,361,RC,50695,CPT,,,,,LT  ,inpatient,facility,,,6801,2856.42,5780.85,6528.96,,5780.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5916.87,,,percent of total billed charges,,,,,,,,,6120.9,,,percent of total billed charges,,,6528.96,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6324.93,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR W NEPH CATH LT S ANDI,3203221,CDM,361,RC,50695,CPT,,,,,LT  ,outpatient,facility,,,6801,2856.42,1836.27,15487,,5780.85,,,percent of total billed charges,,,1836.27,,,percent of total billed charges,,,4679.09,,,percent of total billed charges,,,4577.07,,,percent of total billed charges,,,5746.85,,,percent of total billed charges,,,,,,,,,5916.87,,,percent of total billed charges,,,5916.87,,,percent of total billed charges,,,5780.85,,,percent of total billed charges,,,6528.96,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,6120.9,,,percent of total billed charges,,,,,,,,,6324.93,,,percent of total billed charges,,,6460.95,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6188.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR W NEPH CATH LT S ANDI,3203221,CDM,361,RC,50695,CPT,5374,APC,,,LT  ,outpatient,facility,,,6801,6801,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT URTR W NEPH CATH BI S ANDI,3203239,CDM,361,RC,50695,CPT,,,,,50,inpatient,facility,,,10201,4284.42,8670.85,9792.96,,8670.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8874.87,,,percent of total billed charges,,,,,,,,,9180.9,,,percent of total billed charges,,,9792.96,,,percent of total billed charges,,,9690.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9486.93,,,percent of total billed charges,,,9690.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR W NEPH CATH BI S ANDI,3203239,CDM,361,RC,50695,CPT,,,,,50,outpatient,facility,,,10201,4284.42,2754.27,15487,,8670.85,,,percent of total billed charges,,,2754.27,,,percent of total billed charges,,,7018.29,,,percent of total billed charges,,,6865.27,,,percent of total billed charges,,,8619.84,,,percent of total billed charges,,,,,,,,,8874.87,,,percent of total billed charges,,,8874.87,,,percent of total billed charges,,,8670.85,,,percent of total billed charges,,,9792.96,,,percent of total billed charges,,,9690.95,,,percent of total billed charges,,,,,,,,,9180.9,,,percent of total billed charges,,,,,,,,,9486.93,,,percent of total billed charges,,,9690.95,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,9282.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT URTR W NEPH CATH BI S ANDI,3203239,CDM,361,RC,50695,CPT,5374,APC,,,50,outpatient,facility,,,10201,10201,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
US INTRAVASCULAR NONCORNRY INIT S ANDI,3204179,CDM,361,RC,37252,CPT,,,,,,inpatient,facility,,,3715,1560.3,3157.75,3566.4,,3157.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3232.05,,,percent of total billed charges,,,,,,,,,3343.5,,,percent of total billed charges,,,3566.4,,,percent of total billed charges,,,3529.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3454.95,,,percent of total billed charges,,,3529.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
US INTRAVASCULAR NONCORNRY INIT S ANDI,3204179,CDM,361,RC,37252,CPT,,,,,,outpatient,facility,,,3715,1560.3,1003.05,3715,,3157.75,,,percent of total billed charges,,,1003.05,,,percent of total billed charges,,,2555.92,,,percent of total billed charges,,,2500.19,,,percent of total billed charges,,,3139.17,,,percent of total billed charges,,,,,,,,,3232.05,,,percent of total billed charges,,,3232.05,,,percent of total billed charges,,,3157.75,,,percent of total billed charges,,,3566.4,,,percent of total billed charges,,,3529.25,,,percent of total billed charges,,,,,,,,,3343.5,,,percent of total billed charges,,,,,,,,,3454.95,,,percent of total billed charges,,,3529.25,,,percent of total billed charges,,,,,,,,,,,,,,,3715,,,fee schedule,,,3715,,,fee schedule,,,3715,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3380.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
US INTRAVASCULAR NONCORNRY ADDL S ANDI,3204187,CDM,361,RC,37253,CPT,,,,,,inpatient,facility,,,2972,1248.24,2526.2,2853.12,,2526.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2585.64,,,percent of total billed charges,,,,,,,,,2674.8,,,percent of total billed charges,,,2853.12,,,percent of total billed charges,,,2823.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2763.96,,,percent of total billed charges,,,2823.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
US INTRAVASCULAR NONCORNRY ADDL S ANDI,3204187,CDM,361,RC,37253,CPT,,,,,,outpatient,facility,,,2972,1248.24,802.44,3428,,2526.2,,,percent of total billed charges,,,802.44,,,percent of total billed charges,,,2044.74,,,percent of total billed charges,,,2000.16,,,percent of total billed charges,,,2511.34,,,percent of total billed charges,,,,,,,,,2585.64,,,percent of total billed charges,,,2585.64,,,percent of total billed charges,,,2526.2,,,percent of total billed charges,,,2853.12,,,percent of total billed charges,,,2823.4,,,percent of total billed charges,,,,,,,,,2674.8,,,percent of total billed charges,,,,,,,,,2763.96,,,percent of total billed charges,,,2823.4,,,percent of total billed charges,,,,,,,,,,,,,,,2972,,,fee schedule,,,2972,,,fee schedule,,,2972,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2704.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ CHOLANGIOGRAM ACCESS EXIST S ANDI,3204195,CDM,361,RC,47531,CPT,,,,,,inpatient,facility,,,737,309.54,626.45,707.52,,626.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.19,,,percent of total billed charges,,,,,,,,,663.3,,,percent of total billed charges,,,707.52,,,percent of total billed charges,,,700.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,685.41,,,percent of total billed charges,,,700.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CHOLANGIOGRAM ACCESS EXIST S ANDI,3204195,CDM,361,RC,47531,CPT,,,,,,outpatient,facility,,,737,309.54,198.99,15487,,626.45,,,percent of total billed charges,,,198.99,,,percent of total billed charges,,,507.06,,,percent of total billed charges,,,496,,,percent of total billed charges,,,622.76,,,percent of total billed charges,,,,,,,,,641.19,,,percent of total billed charges,,,641.19,,,percent of total billed charges,,,626.45,,,percent of total billed charges,,,707.52,,,percent of total billed charges,,,700.15,,,percent of total billed charges,,,,,,,,,663.3,,,percent of total billed charges,,,,,,,,,685.41,,,percent of total billed charges,,,700.15,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,670.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ CHOLANGIOGRAM ACCESS EXIST S ANDI,3204195,CDM,361,RC,47531,CPT,5341,APC,,,,outpatient,facility,,,737,737,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ CHOLANGIOGRAM ACCESS NEW S ANDI,3204203,CDM,361,RC,47532,CPT,,,,,,inpatient,facility,,,1448,608.16,1230.8,1390.08,,1230.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1259.76,,,percent of total billed charges,,,,,,,,,1303.2,,,percent of total billed charges,,,1390.08,,,percent of total billed charges,,,1375.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1346.64,,,percent of total billed charges,,,1375.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CHOLANGIOGRAM ACCESS NEW S ANDI,3204203,CDM,361,RC,47532,CPT,,,,,,outpatient,facility,,,1448,608.16,390.96,15487,,1230.8,,,percent of total billed charges,,,390.96,,,percent of total billed charges,,,996.22,,,percent of total billed charges,,,974.5,,,percent of total billed charges,,,1223.56,,,percent of total billed charges,,,,,,,,,1259.76,,,percent of total billed charges,,,1259.76,,,percent of total billed charges,,,1230.8,,,percent of total billed charges,,,1390.08,,,percent of total billed charges,,,1375.6,,,percent of total billed charges,,,,,,,,,1303.2,,,percent of total billed charges,,,,,,,,,1346.64,,,percent of total billed charges,,,1375.6,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,1317.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ CHOLANGIOGRAM ACCESS NEW S ANDI,3204203,CDM,361,RC,47532,CPT,5341,APC,,,,outpatient,facility,,,1448,1448,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH DRN BILIARY PERC EXT S ANDI,3204211,CDM,361,RC,47533,CPT,,,,,,inpatient,facility,,,4576,1921.92,3889.6,4392.96,,3889.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3981.12,,,percent of total billed charges,,,,,,,,,4118.4,,,percent of total billed charges,,,4392.96,,,percent of total billed charges,,,4347.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4255.68,,,percent of total billed charges,,,4347.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH DRN BILIARY PERC EXT S ANDI,3204211,CDM,361,RC,47533,CPT,,,,,,outpatient,facility,,,4576,1921.92,1235.52,15487,,3889.6,,,percent of total billed charges,,,1235.52,,,percent of total billed charges,,,3148.29,,,percent of total billed charges,,,3079.65,,,percent of total billed charges,,,3866.72,,,percent of total billed charges,,,,,,,,,3981.12,,,percent of total billed charges,,,3981.12,,,percent of total billed charges,,,3889.6,,,percent of total billed charges,,,4392.96,,,percent of total billed charges,,,4347.2,,,percent of total billed charges,,,,,,,,,4118.4,,,percent of total billed charges,,,,,,,,,4255.68,,,percent of total billed charges,,,4347.2,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4164.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH DRN BILIARY PERC EXT S ANDI,3204211,CDM,361,RC,47533,CPT,5341,APC,,,,outpatient,facility,,,4576,4576,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH DRN BILIARY INT EXT S ANDI,3204229,CDM,361,RC,47534,CPT,,,,,,inpatient,facility,,,6356,2669.52,5402.6,6101.76,,5402.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5529.72,,,percent of total billed charges,,,,,,,,,5720.4,,,percent of total billed charges,,,6101.76,,,percent of total billed charges,,,6038.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5911.08,,,percent of total billed charges,,,6038.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH DRN BILIARY INT EXT S ANDI,3204229,CDM,361,RC,47534,CPT,,,,,,outpatient,facility,,,6356,2669.52,1716.12,15487,,5402.6,,,percent of total billed charges,,,1716.12,,,percent of total billed charges,,,4372.93,,,percent of total billed charges,,,4277.59,,,percent of total billed charges,,,5370.82,,,percent of total billed charges,,,,,,,,,5529.72,,,percent of total billed charges,,,5529.72,,,percent of total billed charges,,,5402.6,,,percent of total billed charges,,,6101.76,,,percent of total billed charges,,,6038.2,,,percent of total billed charges,,,,,,,,,5720.4,,,percent of total billed charges,,,,,,,,,5911.08,,,percent of total billed charges,,,6038.2,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,5783.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH DRN BILIARY INT EXT S ANDI,3204229,CDM,361,RC,47534,CPT,5341,APC,,,,outpatient,facility,,,6356,6356,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CONVERSION CATH DRN BILIARY EXT S ANDI,3204237,CDM,361,RC,47535,CPT,,,,,,inpatient,facility,,,5445,2286.9,4628.25,5227.2,,4628.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4737.15,,,percent of total billed charges,,,,,,,,,4900.5,,,percent of total billed charges,,,5227.2,,,percent of total billed charges,,,5172.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5063.85,,,percent of total billed charges,,,5172.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CONVERSION CATH DRN BILIARY EXT S ANDI,3204237,CDM,361,RC,47535,CPT,,,,,,outpatient,facility,,,5445,2286.9,1470.15,15487,,4628.25,,,percent of total billed charges,,,1470.15,,,percent of total billed charges,,,3746.16,,,percent of total billed charges,,,3664.48,,,percent of total billed charges,,,4601.02,,,percent of total billed charges,,,,,,,,,4737.15,,,percent of total billed charges,,,4737.15,,,percent of total billed charges,,,4628.25,,,percent of total billed charges,,,5227.2,,,percent of total billed charges,,,5172.75,,,percent of total billed charges,,,,,,,,,4900.5,,,percent of total billed charges,,,,,,,,,5063.85,,,percent of total billed charges,,,5172.75,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4954.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CONVERSION CATH DRN BILIARY EXT S ANDI,3204237,CDM,361,RC,47535,CPT,5341,APC,,,,outpatient,facility,,,5445,5445,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EXCHG CATH DRN BILIARY PERC S ANDI,3204245,CDM,361,RC,47536,CPT,,,,,,inpatient,facility,,,3630,1524.6,3085.5,3484.8,,3085.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3158.1,,,percent of total billed charges,,,,,,,,,3267,,,percent of total billed charges,,,3484.8,,,percent of total billed charges,,,3448.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3375.9,,,percent of total billed charges,,,3448.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EXCHG CATH DRN BILIARY PERC S ANDI,3204245,CDM,361,RC,47536,CPT,,,,,,outpatient,facility,,,3630,1524.6,980.1,15487,,3085.5,,,percent of total billed charges,,,980.1,,,percent of total billed charges,,,2497.44,,,percent of total billed charges,,,2442.99,,,percent of total billed charges,,,3067.35,,,percent of total billed charges,,,,,,,,,3158.1,,,percent of total billed charges,,,3158.1,,,percent of total billed charges,,,3085.5,,,percent of total billed charges,,,3484.8,,,percent of total billed charges,,,3448.5,,,percent of total billed charges,,,,,,,,,3267,,,percent of total billed charges,,,,,,,,,3375.9,,,percent of total billed charges,,,3448.5,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,3303.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EXCHG CATH DRN BILIARY PERC S ANDI,3204245,CDM,361,RC,47536,CPT,5341,APC,,,,outpatient,facility,,,3630,3630,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM CATH DRN BILIARY PERC S ANDI,3204252,CDM,361,RC,47537,CPT,,,,,,inpatient,facility,,,2650,1113,2252.5,2544,,2252.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2305.5,,,percent of total billed charges,,,,,,,,,2385,,,percent of total billed charges,,,2544,,,percent of total billed charges,,,2517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2464.5,,,percent of total billed charges,,,2517.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM CATH DRN BILIARY PERC S ANDI,3204252,CDM,361,RC,47537,CPT,,,,,,outpatient,facility,,,2650,1113,715.5,5933,,2252.5,,,percent of total billed charges,,,715.5,,,percent of total billed charges,,,1823.2,,,percent of total billed charges,,,1783.45,,,percent of total billed charges,,,2239.25,,,percent of total billed charges,,,,,,,,,2305.5,,,percent of total billed charges,,,2305.5,,,percent of total billed charges,,,2252.5,,,percent of total billed charges,,,2544,,,percent of total billed charges,,,2517.5,,,percent of total billed charges,,,,,,,,,2385,,,percent of total billed charges,,,,,,,,,2464.5,,,percent of total billed charges,,,2517.5,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2411.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM CATH DRN BILIARY PERC S ANDI,3204252,CDM,361,RC,47537,CPT,5301,APC,,,,outpatient,facility,,,2650,2650,448.42,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,448.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT S DUCT BILE EXIST S ANDI,3204260,CDM,361,RC,47538,CPT,,,,,,inpatient,facility,,,6796,2854.32,5776.6,6524.16,,5776.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5912.52,,,percent of total billed charges,,,,,,,,,6116.4,,,percent of total billed charges,,,6524.16,,,percent of total billed charges,,,6456.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6320.28,,,percent of total billed charges,,,6456.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S DUCT BILE EXIST S ANDI,3204260,CDM,361,RC,47538,CPT,,,,,,outpatient,facility,,,6796,2854.32,1834.92,28046,,5776.6,,,percent of total billed charges,,,1834.92,,,percent of total billed charges,,,4675.65,,,percent of total billed charges,,,4573.71,,,percent of total billed charges,,,5742.62,,,percent of total billed charges,,,,,,,,,5912.52,,,percent of total billed charges,,,5912.52,,,percent of total billed charges,,,5776.6,,,percent of total billed charges,,,6524.16,,,percent of total billed charges,,,6456.2,,,percent of total billed charges,,,,,,,,,6116.4,,,percent of total billed charges,,,,,,,,,6320.28,,,percent of total billed charges,,,6456.2,,,percent of total billed charges,,,,,,,,,,,,,,,6796,,,fee schedule,,,6796,,,fee schedule,,,6796,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,6184.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT S DUCT BILE EXIST S ANDI,3204260,CDM,361,RC,47538,CPT,5361,APC,,,,outpatient,facility,,,6796,6796,2831.25,8537.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6005.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,8537.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7948.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5887.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5887.92,,,fee schedule,,,5887.92,,,fee schedule,,,2831.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT S DUCT BILE NEW S ANDI,3204278,CDM,361,RC,47539,CPT,,,,,,inpatient,facility,,,12301,5166.42,10455.85,11808.96,,10455.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10701.87,,,percent of total billed charges,,,,,,,,,11070.9,,,percent of total billed charges,,,11808.96,,,percent of total billed charges,,,11685.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11439.93,,,percent of total billed charges,,,11685.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S DUCT BILE NEW S ANDI,3204278,CDM,361,RC,47539,CPT,,,,,,outpatient,facility,,,12301,5166.42,3321.27,28046,,10455.85,,,percent of total billed charges,,,3321.27,,,percent of total billed charges,,,8463.09,,,percent of total billed charges,,,8278.57,,,percent of total billed charges,,,10394.34,,,percent of total billed charges,,,,,,,,,10701.87,,,percent of total billed charges,,,10701.87,,,percent of total billed charges,,,10455.85,,,percent of total billed charges,,,11808.96,,,percent of total billed charges,,,11685.95,,,percent of total billed charges,,,,,,,,,11070.9,,,percent of total billed charges,,,,,,,,,11439.93,,,percent of total billed charges,,,11685.95,,,percent of total billed charges,,,,,,,,,,,,,,,5887.92,,,fee schedule,,,5887.92,,,fee schedule,,,5770.16,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,11193.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT S DUCT BILE NEW S ANDI,3204278,CDM,361,RC,47539,CPT,5361,APC,,,,outpatient,facility,,,12301,12301,2831.25,8537.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6005.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,8537.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7948.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5887.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5887.92,,,fee schedule,,,5887.92,,,fee schedule,,,2831.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT S DUCT BILE NEW W DRN S ANDI,3204286,CDM,361,RC,47540,CPT,,,,,,inpatient,facility,,,12641,5309.22,10744.85,12135.36,,10744.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10997.67,,,percent of total billed charges,,,,,,,,,11376.9,,,percent of total billed charges,,,12135.36,,,percent of total billed charges,,,12008.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11756.13,,,percent of total billed charges,,,12008.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S DUCT BILE NEW W DRN S ANDI,3204286,CDM,361,RC,47540,CPT,,,,,,outpatient,facility,,,12641,5309.22,3413.07,28046,,10744.85,,,percent of total billed charges,,,3413.07,,,percent of total billed charges,,,8697.01,,,percent of total billed charges,,,8507.39,,,percent of total billed charges,,,10681.65,,,percent of total billed charges,,,,,,,,,10997.67,,,percent of total billed charges,,,10997.67,,,percent of total billed charges,,,10744.85,,,percent of total billed charges,,,12135.36,,,percent of total billed charges,,,12008.95,,,percent of total billed charges,,,,,,,,,11376.9,,,percent of total billed charges,,,,,,,,,11756.13,,,percent of total billed charges,,,12008.95,,,percent of total billed charges,,,,,,,,,,,,,,,12641,,,fee schedule,,,12641,,,fee schedule,,,12641,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,11503.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT S DUCT BILE NEW W DRN S ANDI,3204286,CDM,361,RC,47540,CPT,5361,APC,,,,outpatient,facility,,,12641,12641,2831.25,8537.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6005.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,8537.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7948.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5887.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5887.92,,,fee schedule,,,5887.92,,,fee schedule,,,2831.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC ACCS BILI TREE SM BOWEL NEW S ANDI,3204294,CDM,361,RC,47541,CPT,,,,,,inpatient,facility,,,6203,2605.26,5272.55,5954.88,,5272.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5396.61,,,percent of total billed charges,,,,,,,,,5582.7,,,percent of total billed charges,,,5954.88,,,percent of total billed charges,,,5892.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5768.79,,,percent of total billed charges,,,5892.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC ACCS BILI TREE SM BOWEL NEW S ANDI,3204294,CDM,361,RC,47541,CPT,,,,,,outpatient,facility,,,6203,2605.26,1674.81,15487,,5272.55,,,percent of total billed charges,,,1674.81,,,percent of total billed charges,,,4267.66,,,percent of total billed charges,,,4174.62,,,percent of total billed charges,,,5241.53,,,percent of total billed charges,,,,,,,,,5396.61,,,percent of total billed charges,,,5396.61,,,percent of total billed charges,,,5272.55,,,percent of total billed charges,,,5954.88,,,percent of total billed charges,,,5892.85,,,percent of total billed charges,,,,,,,,,5582.7,,,percent of total billed charges,,,,,,,,,5768.79,,,percent of total billed charges,,,5892.85,,,percent of total billed charges,,,,,,,,,,,,,,,7720.21,,,fee schedule,,,7720.21,,,fee schedule,,,7565.81,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,5644.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC ACCS BILI TREE SM BOWEL NEW S ANDI,3204294,CDM,361,RC,47541,CPT,5342,APC,,,,outpatient,facility,,,6203,6203,7720.21,11194.3,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7720.21,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7874.61,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,7720.21,,,fee schedule,,,,,,,,,,,,,,,11194.3,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10422.28,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7720.21,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,7720.21,,,fee schedule,,,7720.21,,,fee schedule,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 1 VW,3204575,CDM,320,RC,72081,CPT,,,,,,inpatient,facility,,,114,47.88,96.9,109.44,,96.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,99.18,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 1 VW,3204575,CDM,320,RC,72081,CPT,,,,,,outpatient,facility,,,114,47.88,30.78,109.44,,96.9,,,percent of total billed charges,,,30.78,,,percent of total billed charges,,,78.43,,,percent of total billed charges,,,76.72,,,percent of total billed charges,,,96.33,,,percent of total billed charges,,,,,,,,,99.18,,,percent of total billed charges,,,99.18,,,percent of total billed charges,,,96.9,,,percent of total billed charges,,,109.44,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,102.6,,,percent of total billed charges,,,,,,,,,106.02,,,percent of total billed charges,,,108.3,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,89.03,,,percent of total billed charges,,,103.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 1 VW,3204575,CDM,320,RC,72081,CPT,5521,APC,,,,outpatient,facility,,,114,114,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE ENTIRE THOR ANDLUMB 2 3 VW,3204583,CDM,320,RC,72082,CPT,,,,,,inpatient,facility,,,184,77.28,156.4,176.64,,156.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.08,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 2 3 VW,3204583,CDM,320,RC,72082,CPT,,,,,,outpatient,facility,,,184,77.28,49.68,176.64,,156.4,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,126.59,,,percent of total billed charges,,,123.83,,,percent of total billed charges,,,155.48,,,percent of total billed charges,,,,,,,,,160.08,,,percent of total billed charges,,,160.08,,,percent of total billed charges,,,156.4,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,143.7,,,percent of total billed charges,,,167.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 2 3 VW,3204583,CDM,320,RC,72082,CPT,5522,APC,,,,outpatient,facility,,,184,184,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE ENTIRE THOR ANDLUMB 4 5 VW,3204591,CDM,320,RC,72083,CPT,,,,,,inpatient,facility,,,217,91.14,184.45,208.32,,184.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,188.79,,,percent of total billed charges,,,,,,,,,195.3,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 4 5 VW,3204591,CDM,320,RC,72083,CPT,,,,,,outpatient,facility,,,217,91.14,58.59,208.32,,184.45,,,percent of total billed charges,,,58.59,,,percent of total billed charges,,,149.3,,,percent of total billed charges,,,146.04,,,percent of total billed charges,,,183.36,,,percent of total billed charges,,,,,,,,,188.79,,,percent of total billed charges,,,188.79,,,percent of total billed charges,,,184.45,,,percent of total billed charges,,,208.32,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,195.3,,,percent of total billed charges,,,,,,,,,201.81,,,percent of total billed charges,,,206.15,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,169.48,,,percent of total billed charges,,,197.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 4 5 VW,3204591,CDM,320,RC,72083,CPT,5522,APC,,,,outpatient,facility,,,217,217,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE ENTIRE THOR ANDLUMB 6 PLUS VW,3204609,CDM,320,RC,72084,CPT,,,,,,inpatient,facility,,,253,106.26,215.05,242.88,,215.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,,,,,,,227.7,,,percent of total billed charges,,,242.88,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,235.29,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 6 PLUS VW,3204609,CDM,320,RC,72084,CPT,,,,,,outpatient,facility,,,253,106.26,68.31,242.88,,215.05,,,percent of total billed charges,,,68.31,,,percent of total billed charges,,,174.06,,,percent of total billed charges,,,170.27,,,percent of total billed charges,,,213.78,,,percent of total billed charges,,,,,,,,,220.11,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,215.05,,,percent of total billed charges,,,242.88,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,227.7,,,percent of total billed charges,,,,,,,,,235.29,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,197.59,,,percent of total billed charges,,,230.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE ENTIRE THOR ANDLUMB 6 PLUS VW,3204609,CDM,320,RC,72084,CPT,5522,APC,,,,outpatient,facility,,,253,253,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIP W PELVIS 1 VW RT,3204617,CDM,320,RC,73501,CPT,,,,,RT  ,inpatient,facility,,,163,68.46,138.55,156.48,,138.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.81,,,percent of total billed charges,,,,,,,,,146.7,,,percent of total billed charges,,,156.48,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,151.59,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 1 VW RT,3204617,CDM,320,RC,73501,CPT,,,,,RT  ,outpatient,facility,,,163,68.46,44.01,156.48,,138.55,,,percent of total billed charges,,,44.01,,,percent of total billed charges,,,112.14,,,percent of total billed charges,,,109.7,,,percent of total billed charges,,,137.73,,,percent of total billed charges,,,,,,,,,141.81,,,percent of total billed charges,,,141.81,,,percent of total billed charges,,,138.55,,,percent of total billed charges,,,156.48,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,146.7,,,percent of total billed charges,,,,,,,,,151.59,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,127.3,,,percent of total billed charges,,,148.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 1 VW RT,3204617,CDM,320,RC,73501,CPT,5521,APC,,,RT  ,outpatient,facility,,,163,163,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIP W PELVIS 1 VW LT,3204625,CDM,320,RC,73501,CPT,,,,,LT  ,inpatient,facility,,,163,68.46,138.55,156.48,,138.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.81,,,percent of total billed charges,,,,,,,,,146.7,,,percent of total billed charges,,,156.48,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,151.59,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 1 VW LT,3204625,CDM,320,RC,73501,CPT,,,,,LT  ,outpatient,facility,,,163,68.46,44.01,156.48,,138.55,,,percent of total billed charges,,,44.01,,,percent of total billed charges,,,112.14,,,percent of total billed charges,,,109.7,,,percent of total billed charges,,,137.73,,,percent of total billed charges,,,,,,,,,141.81,,,percent of total billed charges,,,141.81,,,percent of total billed charges,,,138.55,,,percent of total billed charges,,,156.48,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,146.7,,,percent of total billed charges,,,,,,,,,151.59,,,percent of total billed charges,,,154.85,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,127.3,,,percent of total billed charges,,,148.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 1 VW LT,3204625,CDM,320,RC,73501,CPT,5521,APC,,,LT  ,outpatient,facility,,,163,163,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIP W PELVIS 2 3 VW RT,3204641,CDM,320,RC,73502,CPT,,,,,RT  ,inpatient,facility,,,227,95.34,192.95,217.92,,192.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.49,,,percent of total billed charges,,,,,,,,,204.3,,,percent of total billed charges,,,217.92,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.11,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 2 3 VW RT,3204641,CDM,320,RC,73502,CPT,,,,,RT  ,outpatient,facility,,,227,95.34,61.29,217.92,,192.95,,,percent of total billed charges,,,61.29,,,percent of total billed charges,,,156.18,,,percent of total billed charges,,,152.77,,,percent of total billed charges,,,191.81,,,percent of total billed charges,,,,,,,,,197.49,,,percent of total billed charges,,,197.49,,,percent of total billed charges,,,192.95,,,percent of total billed charges,,,217.92,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,204.3,,,percent of total billed charges,,,,,,,,,211.11,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,177.29,,,percent of total billed charges,,,206.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 2 3 VW RT,3204641,CDM,320,RC,73502,CPT,5521,APC,,,RT  ,outpatient,facility,,,227,227,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIP W PELVIS 2 3 VW LT,3204658,CDM,320,RC,73502,CPT,,,,,LT  ,inpatient,facility,,,227,95.34,192.95,217.92,,192.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,197.49,,,percent of total billed charges,,,,,,,,,204.3,,,percent of total billed charges,,,217.92,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,211.11,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 2 3 VW LT,3204658,CDM,320,RC,73502,CPT,,,,,LT  ,outpatient,facility,,,227,95.34,61.29,217.92,,192.95,,,percent of total billed charges,,,61.29,,,percent of total billed charges,,,156.18,,,percent of total billed charges,,,152.77,,,percent of total billed charges,,,191.81,,,percent of total billed charges,,,,,,,,,197.49,,,percent of total billed charges,,,197.49,,,percent of total billed charges,,,192.95,,,percent of total billed charges,,,217.92,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,204.3,,,percent of total billed charges,,,,,,,,,211.11,,,percent of total billed charges,,,215.65,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,177.29,,,percent of total billed charges,,,206.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 2 3 VW LT,3204658,CDM,320,RC,73502,CPT,5521,APC,,,LT  ,outpatient,facility,,,227,227,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIP W PELVIS 4 PLUS VW RT,3204674,CDM,320,RC,73503,CPT,,,,,RT  ,inpatient,facility,,,283,118.86,240.55,271.68,,240.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.21,,,percent of total billed charges,,,,,,,,,254.7,,,percent of total billed charges,,,271.68,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,263.19,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 4 PLUS VW RT,3204674,CDM,320,RC,73503,CPT,,,,,RT  ,outpatient,facility,,,283,118.86,76.41,271.68,,240.55,,,percent of total billed charges,,,76.41,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,190.46,,,percent of total billed charges,,,239.13,,,percent of total billed charges,,,,,,,,,246.21,,,percent of total billed charges,,,246.21,,,percent of total billed charges,,,240.55,,,percent of total billed charges,,,271.68,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,254.7,,,percent of total billed charges,,,,,,,,,263.19,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,221.02,,,percent of total billed charges,,,257.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 4 PLUS VW RT,3204674,CDM,320,RC,73503,CPT,5522,APC,,,RT  ,outpatient,facility,,,283,283,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIP W PELVIS 4 PLUS VW LT,3204682,CDM,320,RC,73503,CPT,,,,,LT  ,inpatient,facility,,,283,118.86,240.55,271.68,,240.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,246.21,,,percent of total billed charges,,,,,,,,,254.7,,,percent of total billed charges,,,271.68,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,263.19,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 4 PLUS VW LT,3204682,CDM,320,RC,73503,CPT,,,,,LT  ,outpatient,facility,,,283,118.86,76.41,271.68,,240.55,,,percent of total billed charges,,,76.41,,,percent of total billed charges,,,194.7,,,percent of total billed charges,,,190.46,,,percent of total billed charges,,,239.13,,,percent of total billed charges,,,,,,,,,246.21,,,percent of total billed charges,,,246.21,,,percent of total billed charges,,,240.55,,,percent of total billed charges,,,271.68,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,254.7,,,percent of total billed charges,,,,,,,,,263.19,,,percent of total billed charges,,,268.85,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,221.02,,,percent of total billed charges,,,257.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIP W PELVIS 4 PLUS VW LT,3204682,CDM,320,RC,73503,CPT,5522,APC,,,LT  ,outpatient,facility,,,283,283,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIPS W PELVIS 2 VW BI,3204708,CDM,320,RC,73521,CPT,,,,,,inpatient,facility,,,303,127.26,257.55,290.88,,257.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,263.61,,,percent of total billed charges,,,,,,,,,272.7,,,percent of total billed charges,,,290.88,,,percent of total billed charges,,,287.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,281.79,,,percent of total billed charges,,,287.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIPS W PELVIS 2 VW BI,3204708,CDM,320,RC,73521,CPT,,,,,,outpatient,facility,,,303,127.26,81.81,290.88,,257.55,,,percent of total billed charges,,,81.81,,,percent of total billed charges,,,208.46,,,percent of total billed charges,,,203.92,,,percent of total billed charges,,,256.03,,,percent of total billed charges,,,,,,,,,263.61,,,percent of total billed charges,,,263.61,,,percent of total billed charges,,,257.55,,,percent of total billed charges,,,290.88,,,percent of total billed charges,,,287.85,,,percent of total billed charges,,,,,,,,,272.7,,,percent of total billed charges,,,,,,,,,281.79,,,percent of total billed charges,,,287.85,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,236.64,,,percent of total billed charges,,,275.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIPS W PELVIS 2 VW BI,3204708,CDM,320,RC,73521,CPT,5522,APC,,,,outpatient,facility,,,303,303,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIPS W PELVIS 3 4 VW BI,3204716,CDM,320,RC,73522,CPT,,,,,,inpatient,facility,,,394,165.48,334.9,378.24,,334.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,342.78,,,percent of total billed charges,,,,,,,,,354.6,,,percent of total billed charges,,,378.24,,,percent of total billed charges,,,374.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,366.42,,,percent of total billed charges,,,374.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIPS W PELVIS 3 4 VW BI,3204716,CDM,320,RC,73522,CPT,,,,,,outpatient,facility,,,394,165.48,106.38,378.24,,334.9,,,percent of total billed charges,,,106.38,,,percent of total billed charges,,,271.07,,,percent of total billed charges,,,265.16,,,percent of total billed charges,,,332.93,,,percent of total billed charges,,,,,,,,,342.78,,,percent of total billed charges,,,342.78,,,percent of total billed charges,,,334.9,,,percent of total billed charges,,,378.24,,,percent of total billed charges,,,374.3,,,percent of total billed charges,,,,,,,,,354.6,,,percent of total billed charges,,,,,,,,,366.42,,,percent of total billed charges,,,374.3,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,307.71,,,percent of total billed charges,,,358.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIPS W PELVIS 3 4 VW BI,3204716,CDM,320,RC,73522,CPT,5522,APC,,,,outpatient,facility,,,394,394,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HIPS W PELVIS 5 PLUS VW BI,3204724,CDM,320,RC,73523,CPT,,,,,,inpatient,facility,,,462,194.04,392.7,443.52,,392.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.94,,,percent of total billed charges,,,,,,,,,415.8,,,percent of total billed charges,,,443.52,,,percent of total billed charges,,,438.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,429.66,,,percent of total billed charges,,,438.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HIPS W PELVIS 5 PLUS VW BI,3204724,CDM,320,RC,73523,CPT,,,,,,outpatient,facility,,,462,194.04,109.95,443.52,,392.7,,,percent of total billed charges,,,124.74,,,percent of total billed charges,,,317.86,,,percent of total billed charges,,,310.93,,,percent of total billed charges,,,390.39,,,percent of total billed charges,,,,,,,,,401.94,,,percent of total billed charges,,,401.94,,,percent of total billed charges,,,392.7,,,percent of total billed charges,,,443.52,,,percent of total billed charges,,,438.9,,,percent of total billed charges,,,,,,,,,415.8,,,percent of total billed charges,,,,,,,,,429.66,,,percent of total billed charges,,,438.9,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,360.82,,,percent of total billed charges,,,420.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HIPS W PELVIS 5 PLUS VW BI,3204724,CDM,320,RC,73523,CPT,5522,APC,,,,outpatient,facility,,,462,462,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FEMUR 1 VW RT,3204732,CDM,320,RC,73551,CPT,,,,,RT  ,inpatient,facility,,,95,39.9,80.75,91.2,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.65,,,percent of total billed charges,,,,,,,,,85.5,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.35,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FEMUR 1 VW RT,3204732,CDM,320,RC,73551,CPT,,,,,RT  ,outpatient,facility,,,95,39.9,25.65,92.73,,80.75,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,65.36,,,percent of total billed charges,,,63.93,,,percent of total billed charges,,,80.27,,,percent of total billed charges,,,,,,,,,82.65,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,85.5,,,percent of total billed charges,,,,,,,,,88.35,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,74.19,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FEMUR 1 VW RT,3204732,CDM,320,RC,73551,CPT,5521,APC,,,RT  ,outpatient,facility,,,95,95,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FEMUR 1 VW LT,3204740,CDM,320,RC,73551,CPT,,,,,LT  ,inpatient,facility,,,95,39.9,80.75,91.2,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,82.65,,,percent of total billed charges,,,,,,,,,85.5,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,88.35,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FEMUR 1 VW LT,3204740,CDM,320,RC,73551,CPT,,,,,LT  ,outpatient,facility,,,95,39.9,25.65,92.73,,80.75,,,percent of total billed charges,,,25.65,,,percent of total billed charges,,,65.36,,,percent of total billed charges,,,63.93,,,percent of total billed charges,,,80.27,,,percent of total billed charges,,,,,,,,,82.65,,,percent of total billed charges,,,82.65,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,85.5,,,percent of total billed charges,,,,,,,,,88.35,,,percent of total billed charges,,,90.25,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,74.19,,,percent of total billed charges,,,86.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FEMUR 1 VW LT,3204740,CDM,320,RC,73551,CPT,5521,APC,,,LT  ,outpatient,facility,,,95,95,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FEMUR 2 PLUS VW RT,3204765,CDM,320,RC,73552,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FEMUR 2 PLUS VW RT,3204765,CDM,320,RC,73552,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FEMUR 2 PLUS VW RT,3204765,CDM,320,RC,73552,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FEMUR 2 PLUS VW LT,3204773,CDM,320,RC,73552,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FEMUR 2 PLUS VW LT,3204773,CDM,320,RC,73552,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FEMUR 2 PLUS VW LT,3204773,CDM,320,RC,73552,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH NEPHROURET PERC NEW BI S ANDI,3205655,CDM,361,RC,50433,CPT,,,,,50,inpatient,facility,,,5384,2261.28,4576.4,5168.64,,4576.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4684.08,,,percent of total billed charges,,,,,,,,,4845.6,,,percent of total billed charges,,,5168.64,,,percent of total billed charges,,,5114.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5007.12,,,percent of total billed charges,,,5114.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROURET PERC NEW BI S ANDI,3205655,CDM,361,RC,50433,CPT,,,,,50,outpatient,facility,,,5384,2261.28,1453.68,11510,,4576.4,,,percent of total billed charges,,,1453.68,,,percent of total billed charges,,,3704.19,,,percent of total billed charges,,,3623.43,,,percent of total billed charges,,,4549.48,,,percent of total billed charges,,,,,,,,,4684.08,,,percent of total billed charges,,,4684.08,,,percent of total billed charges,,,4576.4,,,percent of total billed charges,,,5168.64,,,percent of total billed charges,,,5114.8,,,percent of total billed charges,,,,,,,,,4845.6,,,percent of total billed charges,,,,,,,,,5007.12,,,percent of total billed charges,,,5114.8,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,4899.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROURET PERC NEW BI S ANDI,3205655,CDM,361,RC,50433,CPT,5374,APC,,,50,outpatient,facility,,,5384,5384,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH NEPHROURET PERC NEW LT S ANDI,3205663,CDM,361,RC,50433,CPT,,,,,LT  ,inpatient,facility,,,3589,1507.38,3050.65,3445.44,,3050.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3122.43,,,percent of total billed charges,,,,,,,,,3230.1,,,percent of total billed charges,,,3445.44,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3337.77,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROURET PERC NEW LT S ANDI,3205663,CDM,361,RC,50433,CPT,,,,,LT  ,outpatient,facility,,,3589,1507.38,969.03,11510,,3050.65,,,percent of total billed charges,,,969.03,,,percent of total billed charges,,,2469.23,,,percent of total billed charges,,,2415.4,,,percent of total billed charges,,,3032.7,,,percent of total billed charges,,,,,,,,,3122.43,,,percent of total billed charges,,,3122.43,,,percent of total billed charges,,,3050.65,,,percent of total billed charges,,,3445.44,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,3230.1,,,percent of total billed charges,,,,,,,,,3337.77,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3265.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROURET PERC NEW LT S ANDI,3205663,CDM,361,RC,50433,CPT,5374,APC,,,LT  ,outpatient,facility,,,3589,3589,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH NEPHROURET PERC NEW RT S ANDI,3205671,CDM,361,RC,50433,CPT,,,,,RT  ,inpatient,facility,,,3589,1507.38,3050.65,3445.44,,3050.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3122.43,,,percent of total billed charges,,,,,,,,,3230.1,,,percent of total billed charges,,,3445.44,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3337.77,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROURET PERC NEW RT S ANDI,3205671,CDM,361,RC,50433,CPT,,,,,RT  ,outpatient,facility,,,3589,1507.38,969.03,11510,,3050.65,,,percent of total billed charges,,,969.03,,,percent of total billed charges,,,2469.23,,,percent of total billed charges,,,2415.4,,,percent of total billed charges,,,3032.7,,,percent of total billed charges,,,,,,,,,3122.43,,,percent of total billed charges,,,3122.43,,,percent of total billed charges,,,3050.65,,,percent of total billed charges,,,3445.44,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,3230.1,,,percent of total billed charges,,,,,,,,,3337.77,,,percent of total billed charges,,,3409.55,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3265.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH NEPHROURET PERC NEW RT S ANDI,3205671,CDM,361,RC,50433,CPT,5374,APC,,,RT  ,outpatient,facility,,,3589,3589,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CNV CATH NEPH PERC PRE EXIST BI S ANDI,3205689,CDM,361,RC,50434,CPT,,,,,50,inpatient,facility,,,7905,3320.1,6719.25,7588.8,,6719.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6877.35,,,percent of total billed charges,,,,,,,,,7114.5,,,percent of total billed charges,,,7588.8,,,percent of total billed charges,,,7509.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7351.65,,,percent of total billed charges,,,7509.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CNV CATH NEPH PERC PRE EXIST BI S ANDI,3205689,CDM,361,RC,50434,CPT,,,,,50,outpatient,facility,,,7905,3320.1,2134.35,7588.8,,6719.25,,,percent of total billed charges,,,2134.35,,,percent of total billed charges,,,5438.64,,,percent of total billed charges,,,5320.06,,,percent of total billed charges,,,6679.72,,,percent of total billed charges,,,,,,,,,6877.35,,,percent of total billed charges,,,6877.35,,,percent of total billed charges,,,6719.25,,,percent of total billed charges,,,7588.8,,,percent of total billed charges,,,7509.75,,,percent of total billed charges,,,,,,,,,7114.5,,,percent of total billed charges,,,,,,,,,7351.65,,,percent of total billed charges,,,7509.75,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,7193.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CNV CATH NEPH PERC PRE EXIST BI S ANDI,3205689,CDM,361,RC,50434,CPT,5374,APC,,,50,outpatient,facility,,,7905,7905,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CNV CATH NEPH PERC PRE EXIST LT S ANDI,3205697,CDM,361,RC,50434,CPT,,,,,LT  ,inpatient,facility,,,5270,2213.4,4479.5,5059.2,,4479.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.9,,,percent of total billed charges,,,,,,,,,4743,,,percent of total billed charges,,,5059.2,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4901.1,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CNV CATH NEPH PERC PRE EXIST LT S ANDI,3205697,CDM,361,RC,50434,CPT,,,,,LT  ,outpatient,facility,,,5270,2213.4,1422.9,5059.2,,4479.5,,,percent of total billed charges,,,1422.9,,,percent of total billed charges,,,3625.76,,,percent of total billed charges,,,3546.71,,,percent of total billed charges,,,4453.15,,,percent of total billed charges,,,,,,,,,4584.9,,,percent of total billed charges,,,4584.9,,,percent of total billed charges,,,4479.5,,,percent of total billed charges,,,5059.2,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,4743,,,percent of total billed charges,,,,,,,,,4901.1,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,4795.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CNV CATH NEPH PERC PRE EXIST LT S ANDI,3205697,CDM,361,RC,50434,CPT,5373,APC,,,LT  ,outpatient,facility,,,5270,5270,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CNV CATH NEPH PERC PRE EXIST RT S ANDI,3205705,CDM,361,RC,50434,CPT,,,,,RT  ,inpatient,facility,,,5270,2213.4,4479.5,5059.2,,4479.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4584.9,,,percent of total billed charges,,,,,,,,,4743,,,percent of total billed charges,,,5059.2,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4901.1,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CNV CATH NEPH PERC PRE EXIST RT S ANDI,3205705,CDM,361,RC,50434,CPT,,,,,RT  ,outpatient,facility,,,5270,2213.4,1422.9,5059.2,,4479.5,,,percent of total billed charges,,,1422.9,,,percent of total billed charges,,,3625.76,,,percent of total billed charges,,,3546.71,,,percent of total billed charges,,,4453.15,,,percent of total billed charges,,,,,,,,,4584.9,,,percent of total billed charges,,,4584.9,,,percent of total billed charges,,,4479.5,,,percent of total billed charges,,,5059.2,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,4743,,,percent of total billed charges,,,,,,,,,4901.1,,,percent of total billed charges,,,5006.5,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,4795.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CNV CATH NEPH PERC PRE EXIST RT S ANDI,3205705,CDM,361,RC,50434,CPT,5373,APC,,,RT  ,outpatient,facility,,,5270,5270,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL BLN DUCT BILIARY PERC EA S ANDI,3205713,CDM,361,RC,47542,CPT,,,,,,inpatient,facility,,,6464,2714.88,5494.4,6205.44,,5494.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5623.68,,,percent of total billed charges,,,,,,,,,5817.6,,,percent of total billed charges,,,6205.44,,,percent of total billed charges,,,6140.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6011.52,,,percent of total billed charges,,,6140.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL BLN DUCT BILIARY PERC EA S ANDI,3205713,CDM,361,RC,47542,CPT,,,,,,outpatient,facility,,,6464,2714.88,1745.28,6464,,5494.4,,,percent of total billed charges,,,1745.28,,,percent of total billed charges,,,4447.23,,,percent of total billed charges,,,4350.27,,,percent of total billed charges,,,5462.08,,,percent of total billed charges,,,,,,,,,5623.68,,,percent of total billed charges,,,5623.68,,,percent of total billed charges,,,5494.4,,,percent of total billed charges,,,6205.44,,,percent of total billed charges,,,6140.8,,,percent of total billed charges,,,,,,,,,5817.6,,,percent of total billed charges,,,,,,,,,6011.52,,,percent of total billed charges,,,6140.8,,,percent of total billed charges,,,,,,,,,,,,,,,6464,,,fee schedule,,,6464,,,fee schedule,,,6464,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,5882.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX S ENDOLMNL BILI TREE PERC S ANDI,3205721,CDM,361,RC,47543,CPT,,,,,,inpatient,facility,,,5228,2195.76,4443.8,5018.88,,4443.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4548.36,,,percent of total billed charges,,,,,,,,,4705.2,,,percent of total billed charges,,,5018.88,,,percent of total billed charges,,,4966.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4862.04,,,percent of total billed charges,,,4966.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX S ENDOLMNL BILI TREE PERC S ANDI,3205721,CDM,361,RC,47543,CPT,,,,,,outpatient,facility,,,5228,2195.76,1411.56,5228,,4443.8,,,percent of total billed charges,,,1411.56,,,percent of total billed charges,,,3596.86,,,percent of total billed charges,,,3518.44,,,percent of total billed charges,,,4417.66,,,percent of total billed charges,,,,,,,,,4548.36,,,percent of total billed charges,,,4548.36,,,percent of total billed charges,,,4443.8,,,percent of total billed charges,,,5018.88,,,percent of total billed charges,,,4966.6,,,percent of total billed charges,,,,,,,,,4705.2,,,percent of total billed charges,,,,,,,,,4862.04,,,percent of total billed charges,,,4966.6,,,percent of total billed charges,,,,,,,,,,,,,,,5228,,,fee schedule,,,5228,,,fee schedule,,,5228,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,4757.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
COLL FLUID SCLEROTX W IMG GD S ANDI,3205739,CDM,361,RC,49185,CPT,,,,,,inpatient,facility,,,2262,950.04,1922.7,2171.52,,1922.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1967.94,,,percent of total billed charges,,,,,,,,,2035.8,,,percent of total billed charges,,,2171.52,,,percent of total billed charges,,,2148.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2103.66,,,percent of total billed charges,,,2148.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
COLL FLUID SCLEROTX W IMG GD S ANDI,3205739,CDM,361,RC,49185,CPT,,,,,,outpatient,facility,,,2262,950.04,610.74,3522,,1922.7,,,percent of total billed charges,,,610.74,,,percent of total billed charges,,,1556.26,,,percent of total billed charges,,,1522.33,,,percent of total billed charges,,,1911.39,,,percent of total billed charges,,,,,,,,,1967.94,,,percent of total billed charges,,,1967.94,,,percent of total billed charges,,,1922.7,,,percent of total billed charges,,,2171.52,,,percent of total billed charges,,,2148.9,,,percent of total billed charges,,,,,,,,,2035.8,,,percent of total billed charges,,,,,,,,,2103.66,,,percent of total billed charges,,,2148.9,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2058.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
COLL FLUID SCLEROTX W IMG GD S ANDI,3205739,CDM,361,RC,49185,CPT,5072,APC,,,,outpatient,facility,,,2262,2262,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EMB OCCL URETERAL BI S ANDI,3205747,CDM,361,RC,50705,CPT,,,,,50,inpatient,facility,,,3583,1504.86,3045.55,3439.68,,3045.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3117.21,,,percent of total billed charges,,,,,,,,,3224.7,,,percent of total billed charges,,,3439.68,,,percent of total billed charges,,,3403.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3332.19,,,percent of total billed charges,,,3403.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL URETERAL BI S ANDI,3205747,CDM,361,RC,50705,CPT,,,,,50,outpatient,facility,,,3583,1504.86,967.41,3583,,3045.55,,,percent of total billed charges,,,967.41,,,percent of total billed charges,,,2465.1,,,percent of total billed charges,,,2411.36,,,percent of total billed charges,,,3027.63,,,percent of total billed charges,,,,,,,,,3117.21,,,percent of total billed charges,,,3117.21,,,percent of total billed charges,,,3045.55,,,percent of total billed charges,,,3439.68,,,percent of total billed charges,,,3403.85,,,percent of total billed charges,,,,,,,,,3224.7,,,percent of total billed charges,,,,,,,,,3332.19,,,percent of total billed charges,,,3403.85,,,percent of total billed charges,,,,,,,,,,,,,,,3583,,,fee schedule,,,3583,,,fee schedule,,,3583,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3260.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL BLN STRICTURE URETERAL BI S ANDI,3205754,CDM,361,RC,50706,CPT,,,,,50,inpatient,facility,,,8204,3445.68,6973.4,7875.84,,6973.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7137.48,,,percent of total billed charges,,,,,,,,,7383.6,,,percent of total billed charges,,,7875.84,,,percent of total billed charges,,,7793.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7629.72,,,percent of total billed charges,,,7793.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL BLN STRICTURE URETERAL BI S ANDI,3205754,CDM,361,RC,50706,CPT,,,,,50,outpatient,facility,,,8204,3445.68,2215.08,8204,,6973.4,,,percent of total billed charges,,,2215.08,,,percent of total billed charges,,,5644.35,,,percent of total billed charges,,,5521.29,,,percent of total billed charges,,,6932.38,,,percent of total billed charges,,,,,,,,,7137.48,,,percent of total billed charges,,,7137.48,,,percent of total billed charges,,,6973.4,,,percent of total billed charges,,,7875.84,,,percent of total billed charges,,,7793.8,,,percent of total billed charges,,,,,,,,,7383.6,,,percent of total billed charges,,,,,,,,,7629.72,,,percent of total billed charges,,,7793.8,,,percent of total billed charges,,,,,,,,,,,,,,,8204,,,fee schedule,,,8204,,,fee schedule,,,8204,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,7465.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECTOMY AND INF TRNSL ART PERC BI,3205762,CDM,361,RC,61645,CPT,,,,,50,inpatient,facility,,,6549,2750.58,5566.65,6287.04,,5566.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5697.63,,,percent of total billed charges,,,,,,,,,5894.1,,,percent of total billed charges,,,6287.04,,,percent of total billed charges,,,6221.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6090.57,,,percent of total billed charges,,,6221.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECTOMY AND INF TRNSL ART PERC BI,3205762,CDM,361,RC,61645,CPT,,,,,50,outpatient,facility,,,6549,2750.58,1768.23,6549,,5566.65,,,percent of total billed charges,,,1768.23,,,percent of total billed charges,,,4505.71,,,percent of total billed charges,,,4407.48,,,percent of total billed charges,,,5533.9,,,percent of total billed charges,,,,,,,,,5697.63,,,percent of total billed charges,,,5697.63,,,percent of total billed charges,,,5566.65,,,percent of total billed charges,,,6287.04,,,percent of total billed charges,,,6221.55,,,percent of total billed charges,,,,,,,,,5894.1,,,percent of total billed charges,,,,,,,,,6090.57,,,percent of total billed charges,,,6221.55,,,percent of total billed charges,,,,,,,,,,,,,,,6549,,,fee schedule,,,6549,,,fee schedule,,,6549,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,5959.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL URETERAL LT S ANDI,3205770,CDM,361,RC,50705,CPT,,,,,LT  ,inpatient,facility,,,2388,1002.96,2029.8,2292.48,,2029.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2077.56,,,percent of total billed charges,,,,,,,,,2149.2,,,percent of total billed charges,,,2292.48,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2220.84,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL URETERAL LT S ANDI,3205770,CDM,361,RC,50705,CPT,,,,,LT  ,outpatient,facility,,,2388,1002.96,644.76,3428,,2029.8,,,percent of total billed charges,,,644.76,,,percent of total billed charges,,,1642.94,,,percent of total billed charges,,,1607.12,,,percent of total billed charges,,,2017.86,,,percent of total billed charges,,,,,,,,,2077.56,,,percent of total billed charges,,,2077.56,,,percent of total billed charges,,,2029.8,,,percent of total billed charges,,,2292.48,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,2149.2,,,percent of total billed charges,,,,,,,,,2220.84,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,,,,,,,2388,,,fee schedule,,,2388,,,fee schedule,,,2388,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2173.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL URETERAL RT S ANDI,3205788,CDM,361,RC,50705,CPT,,,,,RT  ,inpatient,facility,,,2388,1002.96,2029.8,2292.48,,2029.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2077.56,,,percent of total billed charges,,,,,,,,,2149.2,,,percent of total billed charges,,,2292.48,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2220.84,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL URETERAL RT S ANDI,3205788,CDM,361,RC,50705,CPT,,,,,RT  ,outpatient,facility,,,2388,1002.96,644.76,3428,,2029.8,,,percent of total billed charges,,,644.76,,,percent of total billed charges,,,1642.94,,,percent of total billed charges,,,1607.12,,,percent of total billed charges,,,2017.86,,,percent of total billed charges,,,,,,,,,2077.56,,,percent of total billed charges,,,2077.56,,,percent of total billed charges,,,2029.8,,,percent of total billed charges,,,2292.48,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,2149.2,,,percent of total billed charges,,,,,,,,,2220.84,,,percent of total billed charges,,,2268.6,,,percent of total billed charges,,,,,,,,,,,,,,,2388,,,fee schedule,,,2388,,,fee schedule,,,2388,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2173.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL BLN STRICTURE URETERAL LT S ANDI,3205796,CDM,361,RC,50706,CPT,,,,,LT  ,inpatient,facility,,,5469,2296.98,4648.65,5250.24,,4648.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4758.03,,,percent of total billed charges,,,,,,,,,4922.1,,,percent of total billed charges,,,5250.24,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5086.17,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL BLN STRICTURE URETERAL LT S ANDI,3205796,CDM,361,RC,50706,CPT,,,,,LT  ,outpatient,facility,,,5469,2296.98,1476.63,5469,,4648.65,,,percent of total billed charges,,,1476.63,,,percent of total billed charges,,,3762.67,,,percent of total billed charges,,,3680.64,,,percent of total billed charges,,,4621.31,,,percent of total billed charges,,,,,,,,,4758.03,,,percent of total billed charges,,,4758.03,,,percent of total billed charges,,,4648.65,,,percent of total billed charges,,,5250.24,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,4922.1,,,percent of total billed charges,,,,,,,,,5086.17,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,5469,,,fee schedule,,,5469,,,fee schedule,,,5469,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,4976.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL BLN STRICTURE URETERAL RT S ANDI,3205804,CDM,361,RC,50706,CPT,,,,,RT  ,inpatient,facility,,,5469,2296.98,4648.65,5250.24,,4648.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4758.03,,,percent of total billed charges,,,,,,,,,4922.1,,,percent of total billed charges,,,5250.24,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5086.17,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL BLN STRICTURE URETERAL RT S ANDI,3205804,CDM,361,RC,50706,CPT,,,,,RT  ,outpatient,facility,,,5469,2296.98,1476.63,5469,,4648.65,,,percent of total billed charges,,,1476.63,,,percent of total billed charges,,,3762.67,,,percent of total billed charges,,,3680.64,,,percent of total billed charges,,,4621.31,,,percent of total billed charges,,,,,,,,,4758.03,,,percent of total billed charges,,,4758.03,,,percent of total billed charges,,,4648.65,,,percent of total billed charges,,,5250.24,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,4922.1,,,percent of total billed charges,,,,,,,,,5086.17,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,5469,,,fee schedule,,,5469,,,fee schedule,,,5469,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,4976.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECTOMY AND INF TRNSL ART PERC LT,3205812,CDM,361,RC,61645,CPT,,,,,LT  ,inpatient,facility,,,4366,1833.72,3711.1,4191.36,,3711.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3798.42,,,percent of total billed charges,,,,,,,,,3929.4,,,percent of total billed charges,,,4191.36,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4060.38,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECTOMY AND INF TRNSL ART PERC LT,3205812,CDM,361,RC,61645,CPT,,,,,LT  ,outpatient,facility,,,4366,1833.72,1178.82,4366,,3711.1,,,percent of total billed charges,,,1178.82,,,percent of total billed charges,,,3003.81,,,percent of total billed charges,,,2938.32,,,percent of total billed charges,,,3689.27,,,percent of total billed charges,,,,,,,,,3798.42,,,percent of total billed charges,,,3798.42,,,percent of total billed charges,,,3711.1,,,percent of total billed charges,,,4191.36,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,3929.4,,,percent of total billed charges,,,,,,,,,4060.38,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,,,,,,,4366,,,fee schedule,,,4366,,,fee schedule,,,4366,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3973.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECTOMY AND INF TRNSL ART PERC RT,3205820,CDM,361,RC,61645,CPT,,,,,RT  ,inpatient,facility,,,4366,1833.72,3711.1,4191.36,,3711.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3798.42,,,percent of total billed charges,,,,,,,,,3929.4,,,percent of total billed charges,,,4191.36,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4060.38,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECTOMY AND INF TRNSL ART PERC RT,3205820,CDM,361,RC,61645,CPT,,,,,RT  ,outpatient,facility,,,4366,1833.72,1178.82,4366,,3711.1,,,percent of total billed charges,,,1178.82,,,percent of total billed charges,,,3003.81,,,percent of total billed charges,,,2938.32,,,percent of total billed charges,,,3689.27,,,percent of total billed charges,,,,,,,,,3798.42,,,percent of total billed charges,,,3798.42,,,percent of total billed charges,,,3711.1,,,percent of total billed charges,,,4191.36,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,3929.4,,,percent of total billed charges,,,,,,,,,4060.38,,,percent of total billed charges,,,4147.7,,,percent of total billed charges,,,,,,,,,,,,,,,4366,,,fee schedule,,,4366,,,fee schedule,,,4366,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3973.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID SUB C T W IMG,3206265,CDM,361,RC,62321,CPT,,,,,,inpatient,facility,,,2951,1239.42,2508.35,2832.96,,2508.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2567.37,,,percent of total billed charges,,,,,,,,,2655.9,,,percent of total billed charges,,,2832.96,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2744.43,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID SUB C T W IMG,3206265,CDM,361,RC,62321,CPT,,,,,,outpatient,facility,,,2951,1239.42,691.57,3522,,2508.35,,,percent of total billed charges,,,796.77,,,percent of total billed charges,,,2030.29,,,percent of total billed charges,,,1986.02,,,percent of total billed charges,,,2493.59,,,percent of total billed charges,,,,,,,,,2567.37,,,percent of total billed charges,,,2567.37,,,percent of total billed charges,,,2508.35,,,percent of total billed charges,,,2832.96,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,2655.9,,,percent of total billed charges,,,,,,,,,2744.43,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2685.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID SUB C T W IMG,3206265,CDM,361,RC,62321,CPT,5442,APC,,,,outpatient,facility,,,2951,2951,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID SUB L S WO IMG,3206273,CDM,361,RC,62322,CPT,,,,,,inpatient,facility,,,2066,867.72,1756.1,1983.36,,1756.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1797.42,,,percent of total billed charges,,,,,,,,,1859.4,,,percent of total billed charges,,,1983.36,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1921.38,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID SUB L S WO IMG,3206273,CDM,361,RC,62322,CPT,,,,,,outpatient,facility,,,2066,867.72,557.82,3522,,1756.1,,,percent of total billed charges,,,557.82,,,percent of total billed charges,,,1421.41,,,percent of total billed charges,,,1390.42,,,percent of total billed charges,,,1745.77,,,percent of total billed charges,,,,,,,,,1797.42,,,percent of total billed charges,,,1797.42,,,percent of total billed charges,,,1756.1,,,percent of total billed charges,,,1983.36,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,1859.4,,,percent of total billed charges,,,,,,,,,1921.38,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1880.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID SUB L S WO IMG,3206273,CDM,361,RC,62322,CPT,5443,APC,,,,outpatient,facility,,,2066,2066,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID SUB L S W IMG,3206281,CDM,361,RC,62323,CPT,,,,,,inpatient,facility,,,2951,1239.42,2508.35,2832.96,,2508.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2567.37,,,percent of total billed charges,,,,,,,,,2655.9,,,percent of total billed charges,,,2832.96,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2744.43,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID SUB L S W IMG,3206281,CDM,361,RC,62323,CPT,,,,,,outpatient,facility,,,2951,1239.42,691.57,3522,,2508.35,,,percent of total billed charges,,,796.77,,,percent of total billed charges,,,2030.29,,,percent of total billed charges,,,1986.02,,,percent of total billed charges,,,2493.59,,,percent of total billed charges,,,,,,,,,2567.37,,,percent of total billed charges,,,2567.37,,,percent of total billed charges,,,2508.35,,,percent of total billed charges,,,2832.96,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,2655.9,,,percent of total billed charges,,,,,,,,,2744.43,,,percent of total billed charges,,,2803.45,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2685.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID SUB L S W IMG,3206281,CDM,361,RC,62323,CPT,5442,APC,,,,outpatient,facility,,,2951,2951,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
SED MOD SAME 0 4Y INIT 15MN,3206331,CDM,371,RC,99151,CPT,,,,,,inpatient,facility,,,998,419.16,848.3,958.08,,848.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,868.26,,,percent of total billed charges,,,,,,,,,898.2,,,percent of total billed charges,,,958.08,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,928.14,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SED MOD SAME 0 4Y INIT 15MN,3206331,CDM,371,RC,99151,CPT,,,,,,outpatient,facility,,,998,419.16,269.46,998,,848.3,,,percent of total billed charges,,,269.46,,,percent of total billed charges,,,686.62,,,percent of total billed charges,,,671.65,,,percent of total billed charges,,,843.31,,,percent of total billed charges,,,,,,,,,868.26,,,percent of total billed charges,,,868.26,,,percent of total billed charges,,,848.3,,,percent of total billed charges,,,958.08,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,898.2,,,percent of total billed charges,,,,,,,,,928.14,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,,,,,,,998,,,fee schedule,,,998,,,fee schedule,,,998,,,fee schedule,,,,,,,,,779.44,,,percent of total billed charges,,,908.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SED MOD SAME 5 PLUSY INIT 15MN,3206349,CDM,371,RC,99152,CPT,,,,,,inpatient,facility,,,718,301.56,610.3,689.28,,610.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,624.66,,,percent of total billed charges,,,,,,,,,646.2,,,percent of total billed charges,,,689.28,,,percent of total billed charges,,,682.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,667.74,,,percent of total billed charges,,,682.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SED MOD SAME 5 PLUSY INIT 15MN,3206349,CDM,371,RC,99152,CPT,,,,,,outpatient,facility,,,718,301.56,193.86,718,,610.3,,,percent of total billed charges,,,193.86,,,percent of total billed charges,,,493.98,,,percent of total billed charges,,,483.21,,,percent of total billed charges,,,606.71,,,percent of total billed charges,,,,,,,,,624.66,,,percent of total billed charges,,,624.66,,,percent of total billed charges,,,610.3,,,percent of total billed charges,,,689.28,,,percent of total billed charges,,,682.1,,,percent of total billed charges,,,,,,,,,646.2,,,percent of total billed charges,,,,,,,,,667.74,,,percent of total billed charges,,,682.1,,,percent of total billed charges,,,,,,,,,,,,,,,718,,,fee schedule,,,718,,,fee schedule,,,718,,,fee schedule,,,,,,,,,560.76,,,percent of total billed charges,,,653.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SED MOD SAME ADDL 15MN,3206356,CDM,371,RC,99153,CPT,,,,,,inpatient,facility,,,180,75.6,153,172.8,,153,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,156.6,,,percent of total billed charges,,,,,,,,,162,,,percent of total billed charges,,,172.8,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,167.4,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SED MOD SAME ADDL 15MN,3206356,CDM,371,RC,99153,CPT,,,,,,outpatient,facility,,,180,75.6,48.6,180,,153,,,percent of total billed charges,,,48.6,,,percent of total billed charges,,,123.84,,,percent of total billed charges,,,121.14,,,percent of total billed charges,,,152.1,,,percent of total billed charges,,,,,,,,,156.6,,,percent of total billed charges,,,156.6,,,percent of total billed charges,,,153,,,percent of total billed charges,,,172.8,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,162,,,percent of total billed charges,,,,,,,,,167.4,,,percent of total billed charges,,,171,,,percent of total billed charges,,,,,,,,,,,,,,,180,,,fee schedule,,,180,,,fee schedule,,,180,,,fee schedule,,,,,,,,,140.58,,,percent of total billed charges,,,163.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO NDL AND CTH DIAL W DX ANG S ANDI,3206398,CDM,361,RC,36901,CPT,,,,,,inpatient,facility,,,3568,1498.56,3032.8,3425.28,,3032.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3104.16,,,percent of total billed charges,,,,,,,,,3211.2,,,percent of total billed charges,,,3425.28,,,percent of total billed charges,,,3389.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3318.24,,,percent of total billed charges,,,3389.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO NDL AND CTH DIAL W DX ANG S ANDI,3206398,CDM,361,RC,36901,CPT,,,,,,outpatient,facility,,,3568,1498.56,963.36,5933,,3032.8,,,percent of total billed charges,,,963.36,,,percent of total billed charges,,,2454.78,,,percent of total billed charges,,,2401.26,,,percent of total billed charges,,,3014.96,,,percent of total billed charges,,,,,,,,,3104.16,,,percent of total billed charges,,,3104.16,,,percent of total billed charges,,,3032.8,,,percent of total billed charges,,,3425.28,,,percent of total billed charges,,,3389.6,,,percent of total billed charges,,,,,,,,,3211.2,,,percent of total billed charges,,,,,,,,,3318.24,,,percent of total billed charges,,,3389.6,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,3246.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO NDL AND CTH DIAL W DX ANG S ANDI,3206398,CDM,361,RC,36901,CPT,5182,APC,,,,outpatient,facility,,,3568,3568,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INTRO NDL AND CTH DIAL W TBA S ANDI,3206406,CDM,361,RC,36902,CPT,,,,,,inpatient,facility,,,15510,6514.2,13183.5,14889.6,,13183.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13493.7,,,percent of total billed charges,,,,,,,,,13959,,,percent of total billed charges,,,14889.6,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14424.3,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO NDL AND CTH DIAL W TBA S ANDI,3206406,CDM,361,RC,36902,CPT,,,,,,outpatient,facility,,,15510,6514.2,4187.7,28046,,13183.5,,,percent of total billed charges,,,4187.7,,,percent of total billed charges,,,10670.88,,,percent of total billed charges,,,10438.23,,,percent of total billed charges,,,13105.95,,,percent of total billed charges,,,,,,,,,13493.7,,,percent of total billed charges,,,13493.7,,,percent of total billed charges,,,13183.5,,,percent of total billed charges,,,14889.6,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,13959,,,percent of total billed charges,,,,,,,,,14424.3,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,14114.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO NDL AND CTH DIAL W TBA S ANDI,3206406,CDM,361,RC,36902,CPT,5192,APC,,,,outpatient,facility,,,15510,15510,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INTRO NDL AND CTH DIAL W PLC STNT S IV,3206414,CDM,361,RC,36903,CPT,,,,,,inpatient,facility,,,32106,13484.52,27290.1,30821.76,,27290.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27932.22,,,percent of total billed charges,,,,,,,,,28895.4,,,percent of total billed charges,,,30821.76,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29858.58,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO NDL AND CTH DIAL W PLC STNT S IV,3206414,CDM,361,RC,36903,CPT,,,,,,outpatient,facility,,,32106,13484.52,8668.62,32106,,27290.1,,,percent of total billed charges,,,8668.62,,,percent of total billed charges,,,22088.93,,,percent of total billed charges,,,21607.34,,,percent of total billed charges,,,27129.57,,,percent of total billed charges,,,,,,,,,27932.22,,,percent of total billed charges,,,27932.22,,,percent of total billed charges,,,27290.1,,,percent of total billed charges,,,30821.76,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,28895.4,,,percent of total billed charges,,,,,,,,,29858.58,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,,,,,,,32106,,,fee schedule,,,32106,,,fee schedule,,,32106,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,29216.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO NDL AND CTH DIAL W PLC STNT S IV,3206414,CDM,361,RC,36903,CPT,5193,APC,,,,outpatient,facility,,,32106,32106,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBECT AND INF PERC IMG ANG S ANDI,3206422,CDM,361,RC,36904,CPT,,,,,,inpatient,facility,,,15510,6514.2,13183.5,14889.6,,13183.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13493.7,,,percent of total billed charges,,,,,,,,,13959,,,percent of total billed charges,,,14889.6,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14424.3,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT AND INF PERC IMG ANG S ANDI,3206422,CDM,361,RC,36904,CPT,,,,,,outpatient,facility,,,15510,6514.2,4187.7,28046,,13183.5,,,percent of total billed charges,,,4187.7,,,percent of total billed charges,,,10670.88,,,percent of total billed charges,,,10438.23,,,percent of total billed charges,,,13105.95,,,percent of total billed charges,,,,,,,,,13493.7,,,percent of total billed charges,,,13493.7,,,percent of total billed charges,,,13183.5,,,percent of total billed charges,,,14889.6,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,13959,,,percent of total billed charges,,,,,,,,,14424.3,,,percent of total billed charges,,,14734.5,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,14114.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT AND INF PERC IMG ANG S ANDI,3206422,CDM,361,RC,36904,CPT,5192,APC,,,,outpatient,facility,,,15510,15510,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBECT AND INF PERC MECH W TBA S ANDI,3206430,CDM,361,RC,36905,CPT,,,,,,inpatient,facility,,,32106,13484.52,27290.1,30821.76,,27290.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27932.22,,,percent of total billed charges,,,,,,,,,28895.4,,,percent of total billed charges,,,30821.76,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29858.58,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT AND INF PERC MECH W TBA S ANDI,3206430,CDM,361,RC,36905,CPT,,,,,,outpatient,facility,,,32106,13484.52,8668.62,30821.76,,27290.1,,,percent of total billed charges,,,8668.62,,,percent of total billed charges,,,22088.93,,,percent of total billed charges,,,21607.34,,,percent of total billed charges,,,27129.57,,,percent of total billed charges,,,,,,,,,27932.22,,,percent of total billed charges,,,27932.22,,,percent of total billed charges,,,27290.1,,,percent of total billed charges,,,30821.76,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,28895.4,,,percent of total billed charges,,,,,,,,,29858.58,,,percent of total billed charges,,,30500.7,,,percent of total billed charges,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,11001.5,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,29216.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT AND INF PERC MECH W TBA S ANDI,3206430,CDM,361,RC,36905,CPT,5193,APC,,,,outpatient,facility,,,32106,32106,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBECT AND INF PERC W PLC STNT S IV,3206448,CDM,361,RC,36906,CPT,,,,,,inpatient,facility,,,50873,21366.66,43242.05,48838.08,,43242.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44259.51,,,percent of total billed charges,,,,,,,,,45785.7,,,percent of total billed charges,,,48838.08,,,percent of total billed charges,,,48329.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,47311.89,,,percent of total billed charges,,,48329.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT AND INF PERC W PLC STNT S IV,3206448,CDM,361,RC,36906,CPT,,,,,,outpatient,facility,,,50873,21366.66,13735.71,50873,,43242.05,,,percent of total billed charges,,,13735.71,,,percent of total billed charges,,,35000.62,,,percent of total billed charges,,,34237.53,,,percent of total billed charges,,,42987.68,,,percent of total billed charges,,,,,,,,,44259.51,,,percent of total billed charges,,,44259.51,,,percent of total billed charges,,,43242.05,,,percent of total billed charges,,,48838.08,,,percent of total billed charges,,,48329.35,,,percent of total billed charges,,,,,,,,,45785.7,,,percent of total billed charges,,,,,,,,,47311.89,,,percent of total billed charges,,,48329.35,,,percent of total billed charges,,,,,,,,,,,,,,,50873,,,fee schedule,,,50873,,,fee schedule,,,50873,,,fee schedule,,,,,,,,,36446,,,percent of total billed charges,,,46294.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT AND INF PERC W PLC STNT S IV,3206448,CDM,361,RC,36906,CPT,5194,APC,,,,outpatient,facility,,,50873,50873,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TBA DIAL CENTRAL SEG W IMG SI,3206455,CDM,361,RC,36907,CPT,,,,,,inpatient,facility,,,18079,7593.18,15367.15,17355.84,,15367.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15728.73,,,percent of total billed charges,,,,,,,,,16271.1,,,percent of total billed charges,,,17355.84,,,percent of total billed charges,,,17175.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16813.47,,,percent of total billed charges,,,17175.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA DIAL CENTRAL SEG W IMG SI,3206455,CDM,361,RC,36907,CPT,,,,,,outpatient,facility,,,18079,7593.18,3428,18079,,15367.15,,,percent of total billed charges,,,4881.33,,,percent of total billed charges,,,12438.35,,,percent of total billed charges,,,12167.17,,,percent of total billed charges,,,15276.75,,,percent of total billed charges,,,,,,,,,15728.73,,,percent of total billed charges,,,15728.73,,,percent of total billed charges,,,15367.15,,,percent of total billed charges,,,17355.84,,,percent of total billed charges,,,17175.05,,,percent of total billed charges,,,,,,,,,16271.1,,,percent of total billed charges,,,,,,,,,16813.47,,,percent of total billed charges,,,17175.05,,,percent of total billed charges,,,,,,,,,,,,,,,18079,,,fee schedule,,,18079,,,fee schedule,,,18079,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,16451.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART INT BI S ANDI,3206463,CDM,361,RC,37246,CPT,,,,,50,inpatient,facility,,,25925,10888.5,22036.25,24888,,22036.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,22554.75,,,percent of total billed charges,,,,,,,,,23332.5,,,percent of total billed charges,,,24888,,,percent of total billed charges,,,24628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,24110.25,,,percent of total billed charges,,,24628.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART INT BI S ANDI,3206463,CDM,361,RC,37246,CPT,,,,,50,outpatient,facility,,,25925,10888.5,5715.84,28046,,22036.25,,,percent of total billed charges,,,6999.75,,,percent of total billed charges,,,17836.4,,,percent of total billed charges,,,17447.52,,,percent of total billed charges,,,21906.63,,,percent of total billed charges,,,,,,,,,22554.75,,,percent of total billed charges,,,22554.75,,,percent of total billed charges,,,22036.25,,,percent of total billed charges,,,24888,,,percent of total billed charges,,,24628.75,,,percent of total billed charges,,,,,,,,,23332.5,,,percent of total billed charges,,,,,,,,,24110.25,,,percent of total billed charges,,,24628.75,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,23591.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART INT BI S ANDI,3206463,CDM,361,RC,37246,CPT,5192,APC,,,50,outpatient,facility,,,25925,25925,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TBA OPN PRC ART ADL BI S ANDI,3206471,CDM,361,RC,37247,CPT,,,,,50,inpatient,facility,,,12630,5304.6,10735.5,12124.8,,10735.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10988.1,,,percent of total billed charges,,,,,,,,,11367,,,percent of total billed charges,,,12124.8,,,percent of total billed charges,,,11998.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11745.9,,,percent of total billed charges,,,11998.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART ADL BI S ANDI,3206471,CDM,361,RC,37247,CPT,,,,,50,outpatient,facility,,,12630,5304.6,3410.1,12630,,10735.5,,,percent of total billed charges,,,3410.1,,,percent of total billed charges,,,8689.44,,,percent of total billed charges,,,8499.99,,,percent of total billed charges,,,10672.35,,,percent of total billed charges,,,,,,,,,10988.1,,,percent of total billed charges,,,10988.1,,,percent of total billed charges,,,10735.5,,,percent of total billed charges,,,12124.8,,,percent of total billed charges,,,11998.5,,,percent of total billed charges,,,,,,,,,11367,,,percent of total billed charges,,,,,,,,,11745.9,,,percent of total billed charges,,,11998.5,,,percent of total billed charges,,,,,,,,,,,,,,,12630,,,fee schedule,,,12630,,,fee schedule,,,12630,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,11493.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN INT BI S ANDI,3206489,CDM,361,RC,37248,CPT,,,,,50,inpatient,facility,,,22158,9306.36,18834.3,21271.68,,18834.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19277.46,,,percent of total billed charges,,,,,,,,,19942.2,,,percent of total billed charges,,,21271.68,,,percent of total billed charges,,,21050.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20606.94,,,percent of total billed charges,,,21050.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN INT BI S ANDI,3206489,CDM,361,RC,37248,CPT,,,,,50,outpatient,facility,,,22158,9306.36,5715.84,28046,,18834.3,,,percent of total billed charges,,,5982.66,,,percent of total billed charges,,,15244.7,,,percent of total billed charges,,,14912.33,,,percent of total billed charges,,,18723.51,,,percent of total billed charges,,,,,,,,,19277.46,,,percent of total billed charges,,,19277.46,,,percent of total billed charges,,,18834.3,,,percent of total billed charges,,,21271.68,,,percent of total billed charges,,,21050.1,,,percent of total billed charges,,,,,,,,,19942.2,,,percent of total billed charges,,,,,,,,,20606.94,,,percent of total billed charges,,,21050.1,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,20163.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN INT BI S ANDI,3206489,CDM,361,RC,37248,CPT,5192,APC,,,50,outpatient,facility,,,22158,22158,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TBA OPN PRC VEIN ADL BI S ANDI,3206497,CDM,361,RC,37249,CPT,,,,,50,inpatient,facility,,,10858,4560.36,9229.3,10423.68,,9229.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9446.46,,,percent of total billed charges,,,,,,,,,9772.2,,,percent of total billed charges,,,10423.68,,,percent of total billed charges,,,10315.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10097.94,,,percent of total billed charges,,,10315.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN ADL BI S ANDI,3206497,CDM,361,RC,37249,CPT,,,,,50,outpatient,facility,,,10858,4560.36,2931.66,10858,,9229.3,,,percent of total billed charges,,,2931.66,,,percent of total billed charges,,,7470.3,,,percent of total billed charges,,,7307.43,,,percent of total billed charges,,,9175.01,,,percent of total billed charges,,,,,,,,,9446.46,,,percent of total billed charges,,,9446.46,,,percent of total billed charges,,,9229.3,,,percent of total billed charges,,,10423.68,,,percent of total billed charges,,,10315.1,,,percent of total billed charges,,,,,,,,,9772.2,,,percent of total billed charges,,,,,,,,,10097.94,,,percent of total billed charges,,,10315.1,,,percent of total billed charges,,,,,,,,,,,,,,,10858,,,fee schedule,,,10858,,,fee schedule,,,10858,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,9880.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC TRANSCTH STNT S IVASC CDS S ANDI,3206877,CDM,361,RC,36908,CPT,,,,,,inpatient,facility,,,18505,7772.1,15729.25,17764.8,,15729.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16099.35,,,percent of total billed charges,,,,,,,,,16654.5,,,percent of total billed charges,,,17764.8,,,percent of total billed charges,,,17579.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17209.65,,,percent of total billed charges,,,17579.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC TRANSCTH STNT S IVASC CDS S ANDI,3206877,CDM,361,RC,36908,CPT,,,,,,outpatient,facility,,,18505,7772.1,3428,18505,,15729.25,,,percent of total billed charges,,,4996.35,,,percent of total billed charges,,,12731.44,,,percent of total billed charges,,,12453.86,,,percent of total billed charges,,,15636.73,,,percent of total billed charges,,,,,,,,,16099.35,,,percent of total billed charges,,,16099.35,,,percent of total billed charges,,,15729.25,,,percent of total billed charges,,,17764.8,,,percent of total billed charges,,,17579.75,,,percent of total billed charges,,,,,,,,,16654.5,,,percent of total billed charges,,,,,,,,,17209.65,,,percent of total billed charges,,,17579.75,,,percent of total billed charges,,,,,,,,,,,,,,,18505,,,fee schedule,,,18505,,,fee schedule,,,18505,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,16839.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL PERM CIRCUIT DIALYSIS S ANDI,3206885,CDM,361,RC,36909,CPT,,,,,,inpatient,facility,,,16202,6804.84,13771.7,15553.92,,13771.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14095.74,,,percent of total billed charges,,,,,,,,,14581.8,,,percent of total billed charges,,,15553.92,,,percent of total billed charges,,,15391.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15067.86,,,percent of total billed charges,,,15391.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL PERM CIRCUIT DIALYSIS S ANDI,3206885,CDM,361,RC,36909,CPT,,,,,,outpatient,facility,,,16202,6804.84,3428,16202,,13771.7,,,percent of total billed charges,,,4374.54,,,percent of total billed charges,,,11146.98,,,percent of total billed charges,,,10903.95,,,percent of total billed charges,,,13690.69,,,percent of total billed charges,,,,,,,,,14095.74,,,percent of total billed charges,,,14095.74,,,percent of total billed charges,,,13771.7,,,percent of total billed charges,,,15553.92,,,percent of total billed charges,,,15391.9,,,percent of total billed charges,,,,,,,,,14581.8,,,percent of total billed charges,,,,,,,,,15067.86,,,percent of total billed charges,,,15391.9,,,percent of total billed charges,,,,,,,,,,,,,,,16202,,,fee schedule,,,16202,,,fee schedule,,,16202,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,14743.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART INT NONPAIR UNI S ANDI,3207172,CDM,361,RC,37246,CPT,,,,,,inpatient,facility,,,17283,7258.86,14690.55,16591.68,,14690.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15036.21,,,percent of total billed charges,,,,,,,,,15554.7,,,percent of total billed charges,,,16591.68,,,percent of total billed charges,,,16418.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16073.19,,,percent of total billed charges,,,16418.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART INT NONPAIR UNI S ANDI,3207172,CDM,361,RC,37246,CPT,,,,,,outpatient,facility,,,17283,7258.86,4666.41,28046,,14690.55,,,percent of total billed charges,,,4666.41,,,percent of total billed charges,,,11890.7,,,percent of total billed charges,,,11631.46,,,percent of total billed charges,,,14604.14,,,percent of total billed charges,,,,,,,,,15036.21,,,percent of total billed charges,,,15036.21,,,percent of total billed charges,,,14690.55,,,percent of total billed charges,,,16591.68,,,percent of total billed charges,,,16418.85,,,percent of total billed charges,,,,,,,,,15554.7,,,percent of total billed charges,,,,,,,,,16073.19,,,percent of total billed charges,,,16418.85,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,15727.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART INT NONPAIR UNI S ANDI,3207172,CDM,361,RC,37246,CPT,5192,APC,,,,outpatient,facility,,,17283,17283,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TBA OPN PRC ART ADL NONPAIR UNI S ANDI,3207198,CDM,361,RC,37247,CPT,,,,,,inpatient,facility,,,8420,3536.4,7157,8083.2,,7157,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7325.4,,,percent of total billed charges,,,,,,,,,7578,,,percent of total billed charges,,,8083.2,,,percent of total billed charges,,,7999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7830.6,,,percent of total billed charges,,,7999,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC ART ADL NONPAIR UNI S ANDI,3207198,CDM,361,RC,37247,CPT,,,,,,outpatient,facility,,,8420,3536.4,2273.4,8420,,7157,,,percent of total billed charges,,,2273.4,,,percent of total billed charges,,,5792.96,,,percent of total billed charges,,,5666.66,,,percent of total billed charges,,,7114.9,,,percent of total billed charges,,,,,,,,,7325.4,,,percent of total billed charges,,,7325.4,,,percent of total billed charges,,,7157,,,percent of total billed charges,,,8083.2,,,percent of total billed charges,,,7999,,,percent of total billed charges,,,,,,,,,7578,,,percent of total billed charges,,,,,,,,,7830.6,,,percent of total billed charges,,,7999,,,percent of total billed charges,,,,,,,,,,,,,,,8420,,,fee schedule,,,8420,,,fee schedule,,,8420,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,7662.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN INT NONPAIR UNIS ANDI,3207214,CDM,361,RC,37248,CPT,,,,,,inpatient,facility,,,14772,6204.24,12556.2,14181.12,,12556.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12851.64,,,percent of total billed charges,,,,,,,,,13294.8,,,percent of total billed charges,,,14181.12,,,percent of total billed charges,,,14033.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13737.96,,,percent of total billed charges,,,14033.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN INT NONPAIR UNIS ANDI,3207214,CDM,361,RC,37248,CPT,,,,,,outpatient,facility,,,14772,6204.24,3988.44,28046,,12556.2,,,percent of total billed charges,,,3988.44,,,percent of total billed charges,,,10163.14,,,percent of total billed charges,,,9941.56,,,percent of total billed charges,,,12482.34,,,percent of total billed charges,,,,,,,,,12851.64,,,percent of total billed charges,,,12851.64,,,percent of total billed charges,,,12556.2,,,percent of total billed charges,,,14181.12,,,percent of total billed charges,,,14033.4,,,percent of total billed charges,,,,,,,,,13294.8,,,percent of total billed charges,,,,,,,,,13737.96,,,percent of total billed charges,,,14033.4,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,13442.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN INT NONPAIR UNIS ANDI,3207214,CDM,361,RC,37248,CPT,5192,APC,,,,outpatient,facility,,,14772,14772,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TBA OPN PRC VEIN ADL NONPAIR UNIS ANDI,3207230,CDM,361,RC,37249,CPT,,,,,,inpatient,facility,,,7239,3040.38,6153.15,6949.44,,6153.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6297.93,,,percent of total billed charges,,,,,,,,,6515.1,,,percent of total billed charges,,,6949.44,,,percent of total billed charges,,,6877.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6732.27,,,percent of total billed charges,,,6877.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TBA OPN PRC VEIN ADL NONPAIR UNIS ANDI,3207230,CDM,361,RC,37249,CPT,,,,,,outpatient,facility,,,7239,3040.38,1954.53,7239,,6153.15,,,percent of total billed charges,,,1954.53,,,percent of total billed charges,,,4980.43,,,percent of total billed charges,,,4871.85,,,percent of total billed charges,,,6116.95,,,percent of total billed charges,,,,,,,,,6297.93,,,percent of total billed charges,,,6297.93,,,percent of total billed charges,,,6153.15,,,percent of total billed charges,,,6949.44,,,percent of total billed charges,,,6877.05,,,percent of total billed charges,,,,,,,,,6515.1,,,percent of total billed charges,,,,,,,,,6732.27,,,percent of total billed charges,,,6877.05,,,percent of total billed charges,,,,,,,,,,,,,,,7239,,,fee schedule,,,7239,,,fee schedule,,,7239,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,6587.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO PELVIC S ANDI,3207248,CDM,323,RC,75736,CPT,,,,,,inpatient,facility,,,5172,2172.24,4396.2,4965.12,,4396.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4499.64,,,percent of total billed charges,,,,,,,,,4654.8,,,percent of total billed charges,,,4965.12,,,percent of total billed charges,,,4913.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4809.96,,,percent of total billed charges,,,4913.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO PELVIC S ANDI,3207248,CDM,323,RC,75736,CPT,,,,,,outpatient,facility,,,5172,2172.24,1396.44,5607.67,,4396.2,,,percent of total billed charges,,,1396.44,,,percent of total billed charges,,,3558.34,,,percent of total billed charges,,,3480.76,,,percent of total billed charges,,,4370.34,,,percent of total billed charges,,,,,,,,,4499.64,,,percent of total billed charges,,,4499.64,,,percent of total billed charges,,,4396.2,,,percent of total billed charges,,,4965.12,,,percent of total billed charges,,,4913.4,,,percent of total billed charges,,,,,,,,,4654.8,,,percent of total billed charges,,,,,,,,,4809.96,,,percent of total billed charges,,,4913.4,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,4039.33,,,percent of total billed charges,,,4706.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO PELVIC S ANDI,3207248,CDM,323,RC,75736,CPT,5184,APC,,,,outpatient,facility,,,5172,5172,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT REND 3D W I ANDR W PP DIFF WRKST,3207255,CDM,350,RC,76377,CPT,,,,,,inpatient,facility,,,192,80.64,163.2,184.32,,163.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.04,,,percent of total billed charges,,,,,,,,,172.8,,,percent of total billed charges,,,184.32,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.56,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT REND 3D W I ANDR W PP DIFF WRKST,3207255,CDM,350,RC,76377,CPT,,,,,,outpatient,facility,,,192,80.64,51.84,192,,163.2,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,132.1,,,percent of total billed charges,,,129.22,,,percent of total billed charges,,,162.24,,,percent of total billed charges,,,,,,,,,167.04,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,163.2,,,percent of total billed charges,,,184.32,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,172.8,,,percent of total billed charges,,,,,,,,,178.56,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,192,,,fee schedule,,,192,,,fee schedule,,,192,,,fee schedule,,,,,,,,,149.95,,,percent of total billed charges,,,174.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ABSCESS SINUS FISTULA S ANDI,3220001,CDM,320,RC,76080,CPT,,,,,,inpatient,facility,,,905,380.1,769.25,868.8,,769.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,787.35,,,percent of total billed charges,,,,,,,,,814.5,,,percent of total billed charges,,,868.8,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,841.65,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ABSCESS SINUS FISTULA S ANDI,3220001,CDM,320,RC,76080,CPT,,,,,,outpatient,facility,,,905,380.1,244.35,868.8,,769.25,,,percent of total billed charges,,,244.35,,,percent of total billed charges,,,622.64,,,percent of total billed charges,,,609.06,,,percent of total billed charges,,,764.73,,,percent of total billed charges,,,,,,,,,787.35,,,percent of total billed charges,,,787.35,,,percent of total billed charges,,,769.25,,,percent of total billed charges,,,868.8,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,,,,,,,814.5,,,percent of total billed charges,,,,,,,,,841.65,,,percent of total billed charges,,,859.75,,,percent of total billed charges,,,,,,,,,,,,,,,562.95,,,fee schedule,,,562.95,,,fee schedule,,,551.69,,,fee schedule,,,,,,,,,706.8,,,percent of total billed charges,,,823.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ABSCESS SINUS FISTULA S ANDI,3220001,CDM,320,RC,76080,CPT,5524,APC,,,,outpatient,facility,,,905,905,273.3,816.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,562.95,,,fee schedule,,,,,,,,,,,,,,,816.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",759.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,562.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,562.95,,,fee schedule,,,562.95,,,fee schedule,,,273.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ABDOMEN CMP 2 PLUSVW W CHEST 1 VW,3220019,CDM,320,RC,74022,CPT,,,,,,inpatient,facility,,,184,77.28,156.4,176.64,,156.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.08,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN CMP 2 PLUSVW W CHEST 1 VW,3220019,CDM,320,RC,74022,CPT,,,,,,outpatient,facility,,,184,77.28,49.68,176.64,,156.4,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,126.59,,,percent of total billed charges,,,123.83,,,percent of total billed charges,,,155.48,,,percent of total billed charges,,,,,,,,,160.08,,,percent of total billed charges,,,160.08,,,percent of total billed charges,,,156.4,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,143.7,,,percent of total billed charges,,,167.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN CMP 2 PLUSVW W CHEST 1 VW,3220019,CDM,320,RC,74022,CPT,5522,APC,,,,outpatient,facility,,,184,184,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR JTS ACROMIOCLAVICULAR BI,3220050,CDM,320,RC,73050,CPT,,,,,,inpatient,facility,,,167,70.14,141.95,160.32,,141.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.29,,,percent of total billed charges,,,,,,,,,150.3,,,percent of total billed charges,,,160.32,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,155.31,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR JTS ACROMIOCLAVICULAR BI,3220050,CDM,320,RC,73050,CPT,,,,,,outpatient,facility,,,167,70.14,45.09,160.32,,141.95,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,114.9,,,percent of total billed charges,,,112.39,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,,,,,,,145.29,,,percent of total billed charges,,,145.29,,,percent of total billed charges,,,141.95,,,percent of total billed charges,,,160.32,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,150.3,,,percent of total billed charges,,,,,,,,,155.31,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,130.43,,,percent of total billed charges,,,151.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR JTS ACROMIOCLAVICULAR BI,3220050,CDM,320,RC,73050,CPT,5521,APC,,,,outpatient,facility,,,167,167,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ANKLE CMP 3 PLUS VW LT,3220092,CDM,320,RC,73610,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ANKLE CMP 3 PLUS VW LT,3220092,CDM,320,RC,73610,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ANKLE CMP 3 PLUS VW LT,3220092,CDM,320,RC,73610,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ANKLE CMP 3 PLUS VW RT,3220100,CDM,320,RC,73610,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ANKLE CMP 3 PLUS VW RT,3220100,CDM,320,RC,73610,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ANKLE CMP 3 PLUS VW RT,3220100,CDM,320,RC,73610,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ANKLE 2 VW LT,3220126,CDM,320,RC,73600,CPT,,,,,LT  ,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW LT,3220126,CDM,320,RC,73600,CPT,,,,,LT  ,outpatient,facility,,,103,43.26,27.81,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,,,,,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW LT,3220126,CDM,320,RC,73600,CPT,5521,APC,,,LT  ,outpatient,facility,,,103,103,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ANKLE 2 VW RT,3220134,CDM,320,RC,73600,CPT,,,,,RT  ,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW RT,3220134,CDM,320,RC,73600,CPT,,,,,RT  ,outpatient,facility,,,103,43.26,27.81,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,,,,,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW RT,3220134,CDM,320,RC,73600,CPT,5521,APC,,,RT  ,outpatient,facility,,,103,103,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP PUNCT ABSCESS CYST,3220183,CDM,361,RC,10160,CPT,,,,,,inpatient,facility,,,456,191.52,387.6,437.76,,387.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,396.72,,,percent of total billed charges,,,,,,,,,410.4,,,percent of total billed charges,,,437.76,,,percent of total billed charges,,,433.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,424.08,,,percent of total billed charges,,,433.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP PUNCT ABSCESS CYST,3220183,CDM,361,RC,10160,CPT,,,,,,outpatient,facility,,,456,191.52,123.12,3428,,387.6,,,percent of total billed charges,,,123.12,,,percent of total billed charges,,,313.73,,,percent of total billed charges,,,306.89,,,percent of total billed charges,,,385.32,,,percent of total billed charges,,,,,,,,,396.72,,,percent of total billed charges,,,396.72,,,percent of total billed charges,,,387.6,,,percent of total billed charges,,,437.76,,,percent of total billed charges,,,433.2,,,percent of total billed charges,,,,,,,,,410.4,,,percent of total billed charges,,,,,,,,,424.08,,,percent of total billed charges,,,433.2,,,percent of total billed charges,,,,,,,,,,,,,,,406.89,,,fee schedule,,,406.89,,,fee schedule,,,398.75,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,414.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP PUNCT ABSCESS CYST,3220183,CDM,361,RC,10160,CPT,5052,APC,,,,outpatient,facility,,,456,456,202.65,589.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,415.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,406.89,,,fee schedule,,,,,,,,,,,,,,,589.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",549.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,406.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,406.89,,,fee schedule,,,406.89,,,fee schedule,,,202.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ CYST PELVIS RENAL BI,3220233,CDM,361,RC,50390,CPT,,,,,50,inpatient,facility,,,2420,1016.4,2057,2323.2,,2057,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2105.4,,,percent of total billed charges,,,,,,,,,2178,,,percent of total billed charges,,,2323.2,,,percent of total billed charges,,,2299,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2250.6,,,percent of total billed charges,,,2299,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST PELVIS RENAL BI,3220233,CDM,361,RC,50390,CPT,,,,,50,outpatient,facility,,,2420,1016.4,653.4,3522,,2057,,,percent of total billed charges,,,653.4,,,percent of total billed charges,,,1664.96,,,percent of total billed charges,,,1628.66,,,percent of total billed charges,,,2044.9,,,percent of total billed charges,,,,,,,,,2105.4,,,percent of total billed charges,,,2105.4,,,percent of total billed charges,,,2057,,,percent of total billed charges,,,2323.2,,,percent of total billed charges,,,2299,,,percent of total billed charges,,,,,,,,,2178,,,percent of total billed charges,,,,,,,,,2250.6,,,percent of total billed charges,,,2299,,,percent of total billed charges,,,,,,,,,,,,,,,1076.94,,,fee schedule,,,1076.94,,,fee schedule,,,1055.4,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2202.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST PELVIS RENAL BI,3220233,CDM,361,RC,50390,CPT,5071,APC,,,50,outpatient,facility,,,2420,2420,528.79,1561.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1076.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1098.47,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1076.93,,,fee schedule,,,,,,,,,,,,,,,1561.55,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1453.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1076.93,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1076.93,,,fee schedule,,,1076.93,,,fee schedule,,,528.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ CYST PELVIS RENAL LT,3220241,CDM,361,RC,50390,CPT,,,,,LT  ,inpatient,facility,,,1614,677.88,1371.9,1549.44,,1371.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1404.18,,,percent of total billed charges,,,,,,,,,1452.6,,,percent of total billed charges,,,1549.44,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1501.02,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST PELVIS RENAL LT,3220241,CDM,361,RC,50390,CPT,,,,,LT  ,outpatient,facility,,,1614,677.88,435.78,3522,,1371.9,,,percent of total billed charges,,,435.78,,,percent of total billed charges,,,1110.43,,,percent of total billed charges,,,1086.22,,,percent of total billed charges,,,1363.83,,,percent of total billed charges,,,,,,,,,1404.18,,,percent of total billed charges,,,1404.18,,,percent of total billed charges,,,1371.9,,,percent of total billed charges,,,1549.44,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,1452.6,,,percent of total billed charges,,,,,,,,,1501.02,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST PELVIS RENAL LT,3220241,CDM,361,RC,50390,CPT,5071,APC,,,LT  ,outpatient,facility,,,1614,1614,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ CYST PELVIS RENAL RT,3220258,CDM,361,RC,50390,CPT,,,,,RT  ,inpatient,facility,,,1614,677.88,1371.9,1549.44,,1371.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1404.18,,,percent of total billed charges,,,,,,,,,1452.6,,,percent of total billed charges,,,1549.44,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1501.02,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST PELVIS RENAL RT,3220258,CDM,361,RC,50390,CPT,,,,,RT  ,outpatient,facility,,,1614,677.88,435.78,3522,,1371.9,,,percent of total billed charges,,,435.78,,,percent of total billed charges,,,1110.43,,,percent of total billed charges,,,1086.22,,,percent of total billed charges,,,1363.83,,,percent of total billed charges,,,,,,,,,1404.18,,,percent of total billed charges,,,1404.18,,,percent of total billed charges,,,1371.9,,,percent of total billed charges,,,1549.44,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,1452.6,,,percent of total billed charges,,,,,,,,,1501.02,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST PELVIS RENAL RT,3220258,CDM,361,RC,50390,CPT,5071,APC,,,RT  ,outpatient,facility,,,1614,1614,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL BILIARY W STENT,3220316,CDM,361,RC,47556,CPT,,,,,,inpatient,facility,,,5748,2414.16,4885.8,5518.08,,4885.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5000.76,,,percent of total billed charges,,,,,,,,,5173.2,,,percent of total billed charges,,,5518.08,,,percent of total billed charges,,,5460.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5345.64,,,percent of total billed charges,,,5460.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL BILIARY W STENT,3220316,CDM,361,RC,47556,CPT,,,,,,outpatient,facility,,,5748,2414.16,1551.96,28046,,4885.8,,,percent of total billed charges,,,1551.96,,,percent of total billed charges,,,3954.62,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,4857.06,,,percent of total billed charges,,,,,,,,,5000.76,,,percent of total billed charges,,,5000.76,,,percent of total billed charges,,,4885.8,,,percent of total billed charges,,,5518.08,,,percent of total billed charges,,,5460.6,,,percent of total billed charges,,,,,,,,,5173.2,,,percent of total billed charges,,,,,,,,,5345.64,,,percent of total billed charges,,,5460.6,,,percent of total billed charges,,,,,,,,,,,,,,,5748,,,fee schedule,,,5748,,,fee schedule,,,5748,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,5230.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL BILIARY W STENT,3220316,CDM,361,RC,47556,CPT,5362,APC,,,,outpatient,facility,,,5748,5748,4936.25,15230.96,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10504.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10714.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,10504.11,,,fee schedule,,,,,,,,,,,,,,,15230.96,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14180.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,10504.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,10504.11,,,fee schedule,,,10504.11,,,fee schedule,,,4936.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX TRANSCATHETER,3220332,CDM,361,RC,37200,CPT,,,,,,inpatient,facility,,,5487,2304.54,4663.95,5267.52,,4663.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4773.69,,,percent of total billed charges,,,,,,,,,4938.3,,,percent of total billed charges,,,5267.52,,,percent of total billed charges,,,5212.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5102.91,,,percent of total billed charges,,,5212.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX TRANSCATHETER,3220332,CDM,361,RC,37200,CPT,,,,,,outpatient,facility,,,5487,2304.54,1481.49,28046,,4663.95,,,percent of total billed charges,,,1481.49,,,percent of total billed charges,,,3775.06,,,percent of total billed charges,,,3692.75,,,percent of total billed charges,,,4636.51,,,percent of total billed charges,,,,,,,,,4773.69,,,percent of total billed charges,,,4773.69,,,percent of total billed charges,,,4663.95,,,percent of total billed charges,,,5267.52,,,percent of total billed charges,,,5212.65,,,percent of total billed charges,,,,,,,,,4938.3,,,percent of total billed charges,,,,,,,,,5102.91,,,percent of total billed charges,,,5212.65,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,4993.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX TRANSCATHETER,3220332,CDM,361,RC,37200,CPT,5184,APC,,,,outpatient,facility,,,5487,5487,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX TRANSCATHETER S ANDI,3220340,CDM,320,RC,75970,CPT,,,,,,inpatient,facility,,,2447,1027.74,2079.95,2349.12,,2079.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2128.89,,,percent of total billed charges,,,,,,,,,2202.3,,,percent of total billed charges,,,2349.12,,,percent of total billed charges,,,2324.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2275.71,,,percent of total billed charges,,,2324.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX TRANSCATHETER S ANDI,3220340,CDM,320,RC,75970,CPT,,,,,,outpatient,facility,,,2447,1027.74,660.69,2447,,2079.95,,,percent of total billed charges,,,660.69,,,percent of total billed charges,,,1683.54,,,percent of total billed charges,,,1646.83,,,percent of total billed charges,,,2067.72,,,percent of total billed charges,,,,,,,,,2128.89,,,percent of total billed charges,,,2128.89,,,percent of total billed charges,,,2079.95,,,percent of total billed charges,,,2349.12,,,percent of total billed charges,,,2324.65,,,percent of total billed charges,,,,,,,,,2202.3,,,percent of total billed charges,,,,,,,,,2275.71,,,percent of total billed charges,,,2324.65,,,percent of total billed charges,,,,,,,,,,,,,,,2447,,,fee schedule,,,2447,,,fee schedule,,,2447,,,fee schedule,,,,,,,,,1911.11,,,percent of total billed charges,,,2226.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STUDIES AGE BONE,3220357,CDM,320,RC,77072,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STUDIES AGE BONE,3220357,CDM,320,RC,77072,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STUDIES AGE BONE,3220357,CDM,320,RC,77072,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
STUDIES LENGTH BONE,3220365,CDM,320,RC,77073,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STUDIES LENGTH BONE,3220365,CDM,320,RC,77073,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STUDIES LENGTH BONE,3220365,CDM,320,RC,77073,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SURVEY OSSEOUS CMP,3220373,CDM,320,RC,77075,CPT,,,,,,inpatient,facility,,,184,77.28,156.4,176.64,,156.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.08,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SURVEY OSSEOUS CMP,3220373,CDM,320,RC,77075,CPT,,,,,,outpatient,facility,,,184,77.28,49.68,176.64,,156.4,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,126.59,,,percent of total billed charges,,,123.83,,,percent of total billed charges,,,155.48,,,percent of total billed charges,,,,,,,,,160.08,,,percent of total billed charges,,,160.08,,,percent of total billed charges,,,156.4,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,143.7,,,percent of total billed charges,,,167.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SURVEY OSSEOUS CMP,3220373,CDM,320,RC,77075,CPT,5522,APC,,,,outpatient,facility,,,184,184,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SURVEY OSSEOUS INFANT,3220381,CDM,320,RC,77076,CPT,,,,,,inpatient,facility,,,200,84,170,192,,170,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,174,,,percent of total billed charges,,,,,,,,,180,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SURVEY OSSEOUS INFANT,3220381,CDM,320,RC,77076,CPT,,,,,,outpatient,facility,,,200,84,54,192,,170,,,percent of total billed charges,,,54,,,percent of total billed charges,,,137.6,,,percent of total billed charges,,,134.6,,,percent of total billed charges,,,169,,,percent of total billed charges,,,,,,,,,174,,,percent of total billed charges,,,174,,,percent of total billed charges,,,170,,,percent of total billed charges,,,192,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,180,,,percent of total billed charges,,,,,,,,,186,,,percent of total billed charges,,,190,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,156.2,,,percent of total billed charges,,,182,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SURVEY OSSEOUS INFANT,3220381,CDM,320,RC,77076,CPT,5522,APC,,,,outpatient,facility,,,200,200,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SURVEY OSSEOUS LTD,3220399,CDM,320,RC,77074,CPT,,,,,,inpatient,facility,,,134,56.28,113.9,128.64,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.58,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SURVEY OSSEOUS LTD,3220399,CDM,320,RC,77074,CPT,,,,,,outpatient,facility,,,134,56.28,36.18,128.64,,113.9,,,percent of total billed charges,,,36.18,,,percent of total billed charges,,,92.19,,,percent of total billed charges,,,90.18,,,percent of total billed charges,,,113.23,,,percent of total billed charges,,,,,,,,,116.58,,,percent of total billed charges,,,116.58,,,percent of total billed charges,,,113.9,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,104.65,,,percent of total billed charges,,,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SURVEY OSSEOUS LTD,3220399,CDM,320,RC,77074,CPT,5522,APC,,,,outpatient,facility,,,134,134,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX MASS ABD RETRO NDL PERC,3220431,CDM,361,RC,49180,CPT,,,,,,inpatient,facility,,,1917,805.14,1629.45,1840.32,,1629.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1667.79,,,percent of total billed charges,,,,,,,,,1725.3,,,percent of total billed charges,,,1840.32,,,percent of total billed charges,,,1821.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1782.81,,,percent of total billed charges,,,1821.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX MASS ABD RETRO NDL PERC,3220431,CDM,361,RC,49180,CPT,,,,,,outpatient,facility,,,1917,805.14,517.59,5933,,1629.45,,,percent of total billed charges,,,517.59,,,percent of total billed charges,,,1318.9,,,percent of total billed charges,,,1290.14,,,percent of total billed charges,,,1619.87,,,percent of total billed charges,,,,,,,,,1667.79,,,percent of total billed charges,,,1667.79,,,percent of total billed charges,,,1629.45,,,percent of total billed charges,,,1840.32,,,percent of total billed charges,,,1821.15,,,percent of total billed charges,,,,,,,,,1725.3,,,percent of total billed charges,,,,,,,,,1782.81,,,percent of total billed charges,,,1821.15,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1744.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX MASS ABD RETRO NDL PERC,3220431,CDM,361,RC,49180,CPT,5072,APC,,,,outpatient,facility,,,1917,1917,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX BONE TROCAR NDL DEEP,3220449,CDM,361,RC,20225,CPT,,,,,,inpatient,facility,,,2853,1198.26,2425.05,2738.88,,2425.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2482.11,,,percent of total billed charges,,,,,,,,,2567.7,,,percent of total billed charges,,,2738.88,,,percent of total billed charges,,,2710.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2653.29,,,percent of total billed charges,,,2710.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX BONE TROCAR NDL DEEP,3220449,CDM,361,RC,20225,CPT,,,,,,outpatient,facility,,,2853,1198.26,770.31,5933,,2425.05,,,percent of total billed charges,,,770.31,,,percent of total billed charges,,,1962.86,,,percent of total billed charges,,,1920.07,,,percent of total billed charges,,,2410.78,,,percent of total billed charges,,,,,,,,,2482.11,,,percent of total billed charges,,,2482.11,,,percent of total billed charges,,,2425.05,,,percent of total billed charges,,,2738.88,,,percent of total billed charges,,,2710.35,,,percent of total billed charges,,,,,,,,,2567.7,,,percent of total billed charges,,,,,,,,,2653.29,,,percent of total billed charges,,,2710.35,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2596.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX BONE TROCAR NDL DEEP,3220449,CDM,361,RC,20225,CPT,5072,APC,,,,outpatient,facility,,,2853,2853,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX BONE TROCAR NDL SUPERFICIAL,3220456,CDM,361,RC,20220,CPT,,,,,,inpatient,facility,,,1484,623.28,1261.4,1424.64,,1261.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1291.08,,,percent of total billed charges,,,,,,,,,1335.6,,,percent of total billed charges,,,1424.64,,,percent of total billed charges,,,1409.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1380.12,,,percent of total billed charges,,,1409.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX BONE TROCAR NDL SUPERFICIAL,3220456,CDM,361,RC,20220,CPT,,,,,,outpatient,facility,,,1484,623.28,400.68,3522,,1261.4,,,percent of total billed charges,,,400.68,,,percent of total billed charges,,,1020.99,,,percent of total billed charges,,,998.73,,,percent of total billed charges,,,1253.98,,,percent of total billed charges,,,,,,,,,1291.08,,,percent of total billed charges,,,1291.08,,,percent of total billed charges,,,1261.4,,,percent of total billed charges,,,1424.64,,,percent of total billed charges,,,1409.8,,,percent of total billed charges,,,,,,,,,1335.6,,,percent of total billed charges,,,,,,,,,1380.12,,,percent of total billed charges,,,1409.8,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1350.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX BONE TROCAR NDL SUPERFICIAL,3220456,CDM,361,RC,20220,CPT,5072,APC,,,,outpatient,facility,,,1484,1484,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX LIVER NDL PERC,3220464,CDM,361,RC,47000,CPT,,,,,,inpatient,facility,,,2132,895.44,1812.2,2046.72,,1812.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1854.84,,,percent of total billed charges,,,,,,,,,1918.8,,,percent of total billed charges,,,2046.72,,,percent of total billed charges,,,2025.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1982.76,,,percent of total billed charges,,,2025.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX LIVER NDL PERC,3220464,CDM,361,RC,47000,CPT,,,,,,outpatient,facility,,,2132,895.44,575.64,5933,,1812.2,,,percent of total billed charges,,,575.64,,,percent of total billed charges,,,1466.82,,,percent of total billed charges,,,1434.84,,,percent of total billed charges,,,1801.54,,,percent of total billed charges,,,,,,,,,1854.84,,,percent of total billed charges,,,1854.84,,,percent of total billed charges,,,1812.2,,,percent of total billed charges,,,2046.72,,,percent of total billed charges,,,2025.4,,,percent of total billed charges,,,,,,,,,1918.8,,,percent of total billed charges,,,,,,,,,1982.76,,,percent of total billed charges,,,2025.4,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1940.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX LIVER NDL PERC,3220464,CDM,361,RC,47000,CPT,5072,APC,,,,outpatient,facility,,,2132,2132,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX MUSCLE NDL PERC,3220506,CDM,361,RC,20206,CPT,,,,,,inpatient,facility,,,1567,658.14,1331.95,1504.32,,1331.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1363.29,,,percent of total billed charges,,,,,,,,,1410.3,,,percent of total billed charges,,,1504.32,,,percent of total billed charges,,,1488.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1457.31,,,percent of total billed charges,,,1488.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX MUSCLE NDL PERC,3220506,CDM,361,RC,20206,CPT,,,,,,outpatient,facility,,,1567,658.14,423.09,5933,,1331.95,,,percent of total billed charges,,,423.09,,,percent of total billed charges,,,1078.1,,,percent of total billed charges,,,1054.59,,,percent of total billed charges,,,1324.12,,,percent of total billed charges,,,,,,,,,1363.29,,,percent of total billed charges,,,1363.29,,,percent of total billed charges,,,1331.95,,,percent of total billed charges,,,1504.32,,,percent of total billed charges,,,1488.65,,,percent of total billed charges,,,,,,,,,1410.3,,,percent of total billed charges,,,,,,,,,1457.31,,,percent of total billed charges,,,1488.65,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1425.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX MUSCLE NDL PERC,3220506,CDM,361,RC,20206,CPT,5072,APC,,,,outpatient,facility,,,1567,1567,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX THYROID NDL CORE PERC,3220530,CDM,361,RC,60100,CPT,,,,,,inpatient,facility,,,1062,446.04,902.7,1019.52,,902.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,923.94,,,percent of total billed charges,,,,,,,,,955.8,,,percent of total billed charges,,,1019.52,,,percent of total billed charges,,,1008.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,987.66,,,percent of total billed charges,,,1008.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX THYROID NDL CORE PERC,3220530,CDM,361,RC,60100,CPT,,,,,,outpatient,facility,,,1062,446.04,286.74,3522,,902.7,,,percent of total billed charges,,,286.74,,,percent of total billed charges,,,730.66,,,percent of total billed charges,,,714.73,,,percent of total billed charges,,,897.39,,,percent of total billed charges,,,,,,,,,923.94,,,percent of total billed charges,,,923.94,,,percent of total billed charges,,,902.7,,,percent of total billed charges,,,1019.52,,,percent of total billed charges,,,1008.9,,,percent of total billed charges,,,,,,,,,955.8,,,percent of total billed charges,,,,,,,,,987.66,,,percent of total billed charges,,,1008.9,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,966.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX THYROID NDL CORE PERC,3220530,CDM,361,RC,60100,CPT,5071,APC,,,,outpatient,facility,,,1062,1062,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR CALCANEUS 2 PLUS VW LT,3220555,CDM,320,RC,73650,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CALCANEUS 2 PLUS VW LT,3220555,CDM,320,RC,73650,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CALCANEUS 2 PLUS VW LT,3220555,CDM,320,RC,73650,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR CALCANEUS 2 PLUS VW RT,3220563,CDM,320,RC,73650,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CALCANEUS 2 PLUS VW RT,3220563,CDM,320,RC,73650,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CALCANEUS 2 PLUS VW RT,3220563,CDM,320,RC,73650,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHG TUBE CYSTO SIMPLE,3220613,CDM,361,RC,51705,CPT,,,,,,inpatient,facility,,,451,189.42,383.35,432.96,,383.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.37,,,percent of total billed charges,,,,,,,,,405.9,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHG TUBE CYSTO SIMPLE,3220613,CDM,361,RC,51705,CPT,,,,,,outpatient,facility,,,451,189.42,121.77,3428,,383.35,,,percent of total billed charges,,,121.77,,,percent of total billed charges,,,310.29,,,percent of total billed charges,,,303.52,,,percent of total billed charges,,,381.09,,,percent of total billed charges,,,,,,,,,392.37,,,percent of total billed charges,,,392.37,,,percent of total billed charges,,,383.35,,,percent of total billed charges,,,432.96,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,405.9,,,percent of total billed charges,,,,,,,,,419.43,,,percent of total billed charges,,,428.45,,,percent of total billed charges,,,,,,,,,,,,,,,252.2,,,fee schedule,,,252.2,,,fee schedule,,,247.16,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,410.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHG TUBE CYSTO SIMPLE,3220613,CDM,361,RC,51705,CPT,5371,APC,,,,outpatient,facility,,,451,451,116.72,365.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,252.2,,,fee schedule,,,,,,,,,,,,,,,365.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",340.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,252.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,252.2,,,fee schedule,,,252.2,,,fee schedule,,,116.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHG CATH DRN TUBE PERC S ANDI,3220662,CDM,320,RC,75984,CPT,,,,,,inpatient,facility,,,416,174.72,353.6,399.36,,353.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,361.92,,,percent of total billed charges,,,,,,,,,374.4,,,percent of total billed charges,,,399.36,,,percent of total billed charges,,,395.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,386.88,,,percent of total billed charges,,,395.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHG CATH DRN TUBE PERC S ANDI,3220662,CDM,320,RC,75984,CPT,,,,,,outpatient,facility,,,416,174.72,112.32,416,,353.6,,,percent of total billed charges,,,112.32,,,percent of total billed charges,,,286.21,,,percent of total billed charges,,,279.97,,,percent of total billed charges,,,351.52,,,percent of total billed charges,,,,,,,,,361.92,,,percent of total billed charges,,,361.92,,,percent of total billed charges,,,353.6,,,percent of total billed charges,,,399.36,,,percent of total billed charges,,,395.2,,,percent of total billed charges,,,,,,,,,374.4,,,percent of total billed charges,,,,,,,,,386.88,,,percent of total billed charges,,,395.2,,,percent of total billed charges,,,,,,,,,,,,,,,416,,,fee schedule,,,416,,,fee schedule,,,416,,,fee schedule,,,,,,,,,324.9,,,percent of total billed charges,,,378.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHOLANGIO AND PANCREATOGRAM OR ADD S ANDI,3220696,CDM,320,RC,74301,CPT,,,,,,inpatient,facility,,,344,144.48,292.4,330.24,,292.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,299.28,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHOLANGIO AND PANCREATOGRAM OR ADD S ANDI,3220696,CDM,320,RC,74301,CPT,,,,,,outpatient,facility,,,344,144.48,92.88,344,,292.4,,,percent of total billed charges,,,92.88,,,percent of total billed charges,,,236.67,,,percent of total billed charges,,,231.51,,,percent of total billed charges,,,290.68,,,percent of total billed charges,,,,,,,,,299.28,,,percent of total billed charges,,,299.28,,,percent of total billed charges,,,292.4,,,percent of total billed charges,,,330.24,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,309.6,,,percent of total billed charges,,,,,,,,,319.92,,,percent of total billed charges,,,326.8,,,percent of total billed charges,,,,,,,,,,,,,,,344,,,fee schedule,,,344,,,fee schedule,,,344,,,fee schedule,,,,,,,,,268.66,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHOLANGIO AND PANCREATOGRAM OR S ANDI,3220704,CDM,320,RC,74300,CPT,,,,,,inpatient,facility,,,573,240.66,487.05,550.08,,487.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,498.51,,,percent of total billed charges,,,,,,,,,515.7,,,percent of total billed charges,,,550.08,,,percent of total billed charges,,,544.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,532.89,,,percent of total billed charges,,,544.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHOLANGIO AND PANCREATOGRAM OR S ANDI,3220704,CDM,320,RC,74300,CPT,,,,,,outpatient,facility,,,573,240.66,154.71,573,,487.05,,,percent of total billed charges,,,154.71,,,percent of total billed charges,,,394.22,,,percent of total billed charges,,,385.63,,,percent of total billed charges,,,484.19,,,percent of total billed charges,,,,,,,,,498.51,,,percent of total billed charges,,,498.51,,,percent of total billed charges,,,487.05,,,percent of total billed charges,,,550.08,,,percent of total billed charges,,,544.35,,,percent of total billed charges,,,,,,,,,515.7,,,percent of total billed charges,,,,,,,,,532.89,,,percent of total billed charges,,,544.35,,,percent of total billed charges,,,,,,,,,,,,,,,573,,,fee schedule,,,573,,,fee schedule,,,573,,,fee schedule,,,,,,,,,447.51,,,percent of total billed charges,,,521.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CLAVICLE CMP LT,3220803,CDM,320,RC,73000,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CLAVICLE CMP LT,3220803,CDM,320,RC,73000,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CLAVICLE CMP LT,3220803,CDM,320,RC,73000,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR CLAVICLE CMP RT,3220811,CDM,320,RC,73000,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CLAVICLE CMP RT,3220811,CDM,320,RC,73000,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CLAVICLE CMP RT,3220811,CDM,320,RC,73000,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS CVC CENTRAL NONTUN 5 PLUSYRS,3220860,CDM,361,RC,36556,CPT,,,,,,inpatient,facility,,,1874,787.08,1592.9,1799.04,,1592.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1630.38,,,percent of total billed charges,,,,,,,,,1686.6,,,percent of total billed charges,,,1799.04,,,percent of total billed charges,,,1780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1742.82,,,percent of total billed charges,,,1780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS CVC CENTRAL NONTUN 5 PLUSYRS,3220860,CDM,361,RC,36556,CPT,,,,,,outpatient,facility,,,1874,787.08,505.98,3522,,1592.9,,,percent of total billed charges,,,505.98,,,percent of total billed charges,,,1289.31,,,percent of total billed charges,,,1261.2,,,percent of total billed charges,,,1583.53,,,percent of total billed charges,,,,,,,,,1630.38,,,percent of total billed charges,,,1630.38,,,percent of total billed charges,,,1592.9,,,percent of total billed charges,,,1799.04,,,percent of total billed charges,,,1780.3,,,percent of total billed charges,,,,,,,,,1686.6,,,percent of total billed charges,,,,,,,,,1742.82,,,percent of total billed charges,,,1780.3,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1705.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS CVC CENTRAL NONTUN 5 PLUSYRS,3220860,CDM,361,RC,36556,CPT,5183,APC,,,,outpatient,facility,,,1874,1874,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS CVC CENTRAL TUN WO P P 5 PLUSYRS,3220894,CDM,361,RC,36558,CPT,,,,,,inpatient,facility,,,3717,1561.14,3159.45,3568.32,,3159.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3233.79,,,percent of total billed charges,,,,,,,,,3345.3,,,percent of total billed charges,,,3568.32,,,percent of total billed charges,,,3531.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3456.81,,,percent of total billed charges,,,3531.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS CVC CENTRAL TUN WO P P 5 PLUSYRS,3220894,CDM,361,RC,36558,CPT,,,,,,outpatient,facility,,,3717,1561.14,1003.59,15487,,3159.45,,,percent of total billed charges,,,1003.59,,,percent of total billed charges,,,2557.3,,,percent of total billed charges,,,2501.54,,,percent of total billed charges,,,3140.86,,,percent of total billed charges,,,,,,,,,3233.79,,,percent of total billed charges,,,3233.79,,,percent of total billed charges,,,3159.45,,,percent of total billed charges,,,3568.32,,,percent of total billed charges,,,3531.15,,,percent of total billed charges,,,,,,,,,3345.3,,,percent of total billed charges,,,,,,,,,3456.81,,,percent of total billed charges,,,3531.15,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,3382.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS CVC CENTRAL TUN WO P P 5 PLUSYRS,3220894,CDM,361,RC,36558,CPT,5183,APC,,,,outpatient,facility,,,3717,3717,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS CVD CENTRAL TUN W PORT 5 PLUSYRS,3220936,CDM,361,RC,36561,CPT,,,,,,inpatient,facility,,,6702,2814.84,5696.7,6433.92,,5696.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5830.74,,,percent of total billed charges,,,,,,,,,6031.8,,,percent of total billed charges,,,6433.92,,,percent of total billed charges,,,6366.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6232.86,,,percent of total billed charges,,,6366.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS CVD CENTRAL TUN W PORT 5 PLUSYRS,3220936,CDM,361,RC,36561,CPT,,,,,,outpatient,facility,,,6702,2814.84,1809.54,15487,,5696.7,,,percent of total billed charges,,,1809.54,,,percent of total billed charges,,,4610.98,,,percent of total billed charges,,,4510.45,,,percent of total billed charges,,,5663.19,,,percent of total billed charges,,,,,,,,,5830.74,,,percent of total billed charges,,,5830.74,,,percent of total billed charges,,,5696.7,,,percent of total billed charges,,,6433.92,,,percent of total billed charges,,,6366.9,,,percent of total billed charges,,,,,,,,,6031.8,,,percent of total billed charges,,,,,,,,,6232.86,,,percent of total billed charges,,,6366.9,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6098.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS CVD CENTRAL TUN W PORT 5 PLUSYRS,3220936,CDM,361,RC,36561,CPT,5183,APC,,,,outpatient,facility,,,6702,6702,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CYSTOGRAM 3 PLUS VW S ANDI,3220951,CDM,320,RC,74430,CPT,,,,,,inpatient,facility,,,509,213.78,432.65,488.64,,432.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,442.83,,,percent of total billed charges,,,,,,,,,458.1,,,percent of total billed charges,,,488.64,,,percent of total billed charges,,,483.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,473.37,,,percent of total billed charges,,,483.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CYSTOGRAM 3 PLUS VW S ANDI,3220951,CDM,320,RC,74430,CPT,,,,,,outpatient,facility,,,509,213.78,137.43,488.64,,432.65,,,percent of total billed charges,,,137.43,,,percent of total billed charges,,,350.19,,,percent of total billed charges,,,342.56,,,percent of total billed charges,,,430.1,,,percent of total billed charges,,,,,,,,,442.83,,,percent of total billed charges,,,442.83,,,percent of total billed charges,,,432.65,,,percent of total billed charges,,,488.64,,,percent of total billed charges,,,483.55,,,percent of total billed charges,,,,,,,,,458.1,,,percent of total billed charges,,,,,,,,,473.37,,,percent of total billed charges,,,483.55,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,397.53,,,percent of total billed charges,,,463.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CYSTOGRAM 3 PLUS VW S ANDI,3220951,CDM,320,RC,74430,CPT,5572,APC,,,,outpatient,facility,,,509,509,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DECLOT CATH VAD W AGENT THROMB,3221009,CDM,361,RC,36593,CPT,,,,,,inpatient,facility,,,215,90.3,182.75,206.4,,182.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.05,,,percent of total billed charges,,,,,,,,,193.5,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,204.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,199.95,,,percent of total billed charges,,,204.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DECLOT CATH VAD W AGENT THROMB,3221009,CDM,361,RC,36593,CPT,,,,,,outpatient,facility,,,215,90.3,58.05,3428,,182.75,,,percent of total billed charges,,,58.05,,,percent of total billed charges,,,147.92,,,percent of total billed charges,,,144.69,,,percent of total billed charges,,,181.67,,,percent of total billed charges,,,,,,,,,187.05,,,percent of total billed charges,,,187.05,,,percent of total billed charges,,,182.75,,,percent of total billed charges,,,206.4,,,percent of total billed charges,,,204.25,,,percent of total billed charges,,,,,,,,,193.5,,,percent of total billed charges,,,,,,,,,199.95,,,percent of total billed charges,,,204.25,,,percent of total billed charges,,,,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,338.68,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,195.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DECLOT CATH VAD W AGENT THROMB,3221009,CDM,361,RC,36593,CPT,5694,APC,,,,outpatient,facility,,,215,215,180.68,501.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,501.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",466.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,345.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,180.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL BILIARY WO STENT,3221132,CDM,361,RC,47555,CPT,,,,,,inpatient,facility,,,5087,2136.54,4323.95,4883.52,,4323.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4425.69,,,percent of total billed charges,,,,,,,,,4578.3,,,percent of total billed charges,,,4883.52,,,percent of total billed charges,,,4832.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4730.91,,,percent of total billed charges,,,4832.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL BILIARY WO STENT,3221132,CDM,361,RC,47555,CPT,,,,,,outpatient,facility,,,5087,2136.54,1373.49,15487,,4323.95,,,percent of total billed charges,,,1373.49,,,percent of total billed charges,,,3499.86,,,percent of total billed charges,,,3423.55,,,percent of total billed charges,,,4298.51,,,percent of total billed charges,,,,,,,,,4425.69,,,percent of total billed charges,,,4425.69,,,percent of total billed charges,,,4323.95,,,percent of total billed charges,,,4883.52,,,percent of total billed charges,,,4832.65,,,percent of total billed charges,,,,,,,,,4578.3,,,percent of total billed charges,,,,,,,,,4730.91,,,percent of total billed charges,,,4832.65,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4629.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL BILIARY WO STENT,3221132,CDM,361,RC,47555,CPT,5341,APC,,,,outpatient,facility,,,5087,5087,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DISCOGRAM LUMBAR S ANDI,3221157,CDM,320,RC,72295,CPT,,,,,,inpatient,facility,,,5577,2342.34,4740.45,5353.92,,4740.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4851.99,,,percent of total billed charges,,,,,,,,,5019.3,,,percent of total billed charges,,,5353.92,,,percent of total billed charges,,,5298.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5186.61,,,percent of total billed charges,,,5298.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DISCOGRAM LUMBAR S ANDI,3221157,CDM,320,RC,72295,CPT,,,,,,outpatient,facility,,,5577,2342.34,1505.79,5353.92,,4740.45,,,percent of total billed charges,,,1505.79,,,percent of total billed charges,,,3836.98,,,percent of total billed charges,,,3753.32,,,percent of total billed charges,,,4712.56,,,percent of total billed charges,,,,,,,,,4851.99,,,percent of total billed charges,,,4851.99,,,percent of total billed charges,,,4740.45,,,percent of total billed charges,,,5353.92,,,percent of total billed charges,,,5298.15,,,percent of total billed charges,,,,,,,,,5019.3,,,percent of total billed charges,,,,,,,,,5186.61,,,percent of total billed charges,,,5298.15,,,percent of total billed charges,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,1930.84,,,fee schedule,,,,,,,,,4355.64,,,percent of total billed charges,,,5075.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DISCOGRAM LUMBAR S ANDI,3221157,CDM,320,RC,72295,CPT,5431,APC,,,,outpatient,facility,,,5577,5577,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ELBOW CMP 3 PLUS VW LT,3221231,CDM,320,RC,73080,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ELBOW CMP 3 PLUS VW LT,3221231,CDM,320,RC,73080,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ELBOW CMP 3 PLUS VW LT,3221231,CDM,320,RC,73080,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ELBOW CMP 3 PLUS VW RT,3221249,CDM,320,RC,73080,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ELBOW CMP 3 PLUS VW RT,3221249,CDM,320,RC,73080,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ELBOW CMP 3 PLUS VW RT,3221249,CDM,320,RC,73080,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ELBOW 2 VW LT,3221264,CDM,320,RC,73070,CPT,,,,,LT  ,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW LT,3221264,CDM,320,RC,73070,CPT,,,,,LT  ,outpatient,facility,,,100,42,27,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,,,,,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW LT,3221264,CDM,320,RC,73070,CPT,5521,APC,,,LT  ,outpatient,facility,,,100,100,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ELBOW 2 VW RT,3221272,CDM,320,RC,73070,CPT,,,,,RT  ,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW RT,3221272,CDM,320,RC,73070,CPT,,,,,RT  ,outpatient,facility,,,100,42,27,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,,,,,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW RT,3221272,CDM,320,RC,73070,CPT,5521,APC,,,RT  ,outpatient,facility,,,100,100,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CATH ENDO DUCT BILIARY S ANDI,3221306,CDM,320,RC,74328,CPT,,,,,,inpatient,facility,,,1004,421.68,853.4,963.84,,853.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,873.48,,,percent of total billed charges,,,,,,,,,903.6,,,percent of total billed charges,,,963.84,,,percent of total billed charges,,,953.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,933.72,,,percent of total billed charges,,,953.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ENDO DUCT BILIARY S ANDI,3221306,CDM,320,RC,74328,CPT,,,,,,outpatient,facility,,,1004,421.68,271.08,1004,,853.4,,,percent of total billed charges,,,271.08,,,percent of total billed charges,,,690.75,,,percent of total billed charges,,,675.69,,,percent of total billed charges,,,848.38,,,percent of total billed charges,,,,,,,,,873.48,,,percent of total billed charges,,,873.48,,,percent of total billed charges,,,853.4,,,percent of total billed charges,,,963.84,,,percent of total billed charges,,,953.8,,,percent of total billed charges,,,,,,,,,903.6,,,percent of total billed charges,,,,,,,,,933.72,,,percent of total billed charges,,,953.8,,,percent of total billed charges,,,,,,,,,,,,,,,1004,,,fee schedule,,,1004,,,fee schedule,,,1004,,,fee schedule,,,,,,,,,784.12,,,percent of total billed charges,,,913.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH ENDO DUCT PANCREAS S ANDI,3221314,CDM,320,RC,74329,CPT,,,,,,inpatient,facility,,,984,413.28,836.4,944.64,,836.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,856.08,,,percent of total billed charges,,,,,,,,,885.6,,,percent of total billed charges,,,944.64,,,percent of total billed charges,,,934.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,915.12,,,percent of total billed charges,,,934.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ENDO DUCT PANCREAS S ANDI,3221314,CDM,320,RC,74329,CPT,,,,,,outpatient,facility,,,984,413.28,265.68,984,,836.4,,,percent of total billed charges,,,265.68,,,percent of total billed charges,,,676.99,,,percent of total billed charges,,,662.23,,,percent of total billed charges,,,831.48,,,percent of total billed charges,,,,,,,,,856.08,,,percent of total billed charges,,,856.08,,,percent of total billed charges,,,836.4,,,percent of total billed charges,,,944.64,,,percent of total billed charges,,,934.8,,,percent of total billed charges,,,,,,,,,885.6,,,percent of total billed charges,,,,,,,,,915.12,,,percent of total billed charges,,,934.8,,,percent of total billed charges,,,,,,,,,,,,,,,984,,,fee schedule,,,984,,,fee schedule,,,984,,,fee schedule,,,,,,,,,768.5,,,percent of total billed charges,,,895.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ENEMA THERAPEUTIC,3221330,CDM,320,RC,74283,CPT,,,,,,inpatient,facility,,,410,172.2,348.5,393.6,,348.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,356.7,,,percent of total billed charges,,,,,,,,,369,,,percent of total billed charges,,,393.6,,,percent of total billed charges,,,389.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,381.3,,,percent of total billed charges,,,389.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ENEMA THERAPEUTIC,3221330,CDM,320,RC,74283,CPT,,,,,,outpatient,facility,,,410,172.2,110.7,393.6,,348.5,,,percent of total billed charges,,,110.7,,,percent of total billed charges,,,282.08,,,percent of total billed charges,,,275.93,,,percent of total billed charges,,,346.45,,,percent of total billed charges,,,,,,,,,356.7,,,percent of total billed charges,,,356.7,,,percent of total billed charges,,,348.5,,,percent of total billed charges,,,393.6,,,percent of total billed charges,,,389.5,,,percent of total billed charges,,,,,,,,,369,,,percent of total billed charges,,,,,,,,,381.3,,,percent of total billed charges,,,389.5,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,320.21,,,percent of total billed charges,,,373.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ENEMA THERAPEUTIC,3221330,CDM,320,RC,74283,CPT,5571,APC,,,,outpatient,facility,,,410,410,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CATH ENDO DUCT BILIARY ANDPANCREAS S ANDI,3221371,CDM,320,RC,74330,CPT,,,,,,inpatient,facility,,,971,407.82,825.35,932.16,,825.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,844.77,,,percent of total billed charges,,,,,,,,,873.9,,,percent of total billed charges,,,932.16,,,percent of total billed charges,,,922.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,903.03,,,percent of total billed charges,,,922.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH ENDO DUCT BILIARY ANDPANCREAS S ANDI,3221371,CDM,320,RC,74330,CPT,,,,,,outpatient,facility,,,971,407.82,262.17,971,,825.35,,,percent of total billed charges,,,262.17,,,percent of total billed charges,,,668.05,,,percent of total billed charges,,,653.48,,,percent of total billed charges,,,820.5,,,percent of total billed charges,,,,,,,,,844.77,,,percent of total billed charges,,,844.77,,,percent of total billed charges,,,825.35,,,percent of total billed charges,,,932.16,,,percent of total billed charges,,,922.45,,,percent of total billed charges,,,,,,,,,873.9,,,percent of total billed charges,,,,,,,,,903.03,,,percent of total billed charges,,,922.45,,,percent of total billed charges,,,,,,,,,,,,,,,971,,,fee schedule,,,971,,,fee schedule,,,971,,,fee schedule,,,,,,,,,758.35,,,percent of total billed charges,,,883.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EXCHG CATH DRN ABSC CYST,3221421,CDM,361,RC,49423,CPT,,,,,,inpatient,facility,,,3632,1525.44,3087.2,3486.72,,3087.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3159.84,,,percent of total billed charges,,,,,,,,,3268.8,,,percent of total billed charges,,,3486.72,,,percent of total billed charges,,,3450.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3377.76,,,percent of total billed charges,,,3450.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EXCHG CATH DRN ABSC CYST,3221421,CDM,361,RC,49423,CPT,,,,,,outpatient,facility,,,3632,1525.44,980.64,5933,,3087.2,,,percent of total billed charges,,,980.64,,,percent of total billed charges,,,2498.82,,,percent of total billed charges,,,2444.34,,,percent of total billed charges,,,3069.04,,,percent of total billed charges,,,,,,,,,3159.84,,,percent of total billed charges,,,3159.84,,,percent of total billed charges,,,3087.2,,,percent of total billed charges,,,3486.72,,,percent of total billed charges,,,3450.4,,,percent of total billed charges,,,,,,,,,3268.8,,,percent of total billed charges,,,,,,,,,3377.76,,,percent of total billed charges,,,3450.4,,,percent of total billed charges,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,1902.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,3305.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EXCHG CATH DRN ABSC CYST,3221421,CDM,361,RC,49423,CPT,5302,APC,,,,outpatient,facility,,,3632,3632,946.03,2815.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,2815.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2621.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1941.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,946.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR BONES FACIAL 0 2 VW,3221470,CDM,320,RC,70140,CPT,,,,,,inpatient,facility,,,78,32.76,66.3,74.88,,66.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,67.86,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR BONES FACIAL 0 2 VW,3221470,CDM,320,RC,70140,CPT,,,,,,outpatient,facility,,,78,32.76,21.06,92.73,,66.3,,,percent of total billed charges,,,21.06,,,percent of total billed charges,,,53.66,,,percent of total billed charges,,,52.49,,,percent of total billed charges,,,65.91,,,percent of total billed charges,,,,,,,,,67.86,,,percent of total billed charges,,,67.86,,,percent of total billed charges,,,66.3,,,percent of total billed charges,,,74.88,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,70.2,,,percent of total billed charges,,,,,,,,,72.54,,,percent of total billed charges,,,74.1,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,60.92,,,percent of total billed charges,,,70.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR BONES FACIAL 0 2 VW,3221470,CDM,320,RC,70140,CPT,5521,APC,,,,outpatient,facility,,,78,78,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR BONES FACIAL CMP 3 PLUS VW,3221488,CDM,320,RC,70150,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR BONES FACIAL CMP 3 PLUS VW,3221488,CDM,320,RC,70150,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR BONES FACIAL CMP 3 PLUS VW,3221488,CDM,320,RC,70150,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FB NOSE TO RECTUM CHILD 1 VW,3221496,CDM,320,RC,76010,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FB NOSE TO RECTUM CHILD 1 VW,3221496,CDM,320,RC,76010,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FB NOSE TO RECTUM CHILD 1 VW,3221496,CDM,320,RC,76010,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FINGER S 2 PLUS VW LT,3221538,CDM,320,RC,73140,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FINGER S 2 PLUS VW LT,3221538,CDM,320,RC,73140,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FINGER S 2 PLUS VW LT,3221538,CDM,320,RC,73140,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FINGER S 2 PLUS VW RT,3221546,CDM,320,RC,73140,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FINGER S 2 PLUS VW RT,3221546,CDM,320,RC,73140,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FINGER S 2 PLUS VW RT,3221546,CDM,320,RC,73140,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
FLUORO GD PLC REPL REM CVAD,3221553,CDM,320,RC,77001,CPT,,,,,,inpatient,facility,,,294,123.48,249.9,282.24,,249.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.78,,,percent of total billed charges,,,,,,,,,264.6,,,percent of total billed charges,,,282.24,,,percent of total billed charges,,,279.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,273.42,,,percent of total billed charges,,,279.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FLUORO GD PLC REPL REM CVAD,3221553,CDM,320,RC,77001,CPT,,,,,,outpatient,facility,,,294,123.48,79.38,294,,249.9,,,percent of total billed charges,,,79.38,,,percent of total billed charges,,,202.27,,,percent of total billed charges,,,197.86,,,percent of total billed charges,,,248.43,,,percent of total billed charges,,,,,,,,,255.78,,,percent of total billed charges,,,255.78,,,percent of total billed charges,,,249.9,,,percent of total billed charges,,,282.24,,,percent of total billed charges,,,279.3,,,percent of total billed charges,,,,,,,,,264.6,,,percent of total billed charges,,,,,,,,,273.42,,,percent of total billed charges,,,279.3,,,percent of total billed charges,,,,,,,,,,,,,,,294,,,fee schedule,,,294,,,fee schedule,,,294,,,fee schedule,,,,,,,,,229.61,,,percent of total billed charges,,,267.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
GD W PLC CATH DRN PERC S ANDI,3221561,CDM,320,RC,75989,CPT,,,,,,inpatient,facility,,,1949,818.58,1656.65,1871.04,,1656.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1695.63,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
GD W PLC CATH DRN PERC S ANDI,3221561,CDM,320,RC,75989,CPT,,,,,,outpatient,facility,,,1949,818.58,526.23,1949,,1656.65,,,percent of total billed charges,,,526.23,,,percent of total billed charges,,,1340.91,,,percent of total billed charges,,,1311.68,,,percent of total billed charges,,,1646.9,,,percent of total billed charges,,,,,,,,,1695.63,,,percent of total billed charges,,,1695.63,,,percent of total billed charges,,,1656.65,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,1949,,,fee schedule,,,1949,,,fee schedule,,,1949,,,fee schedule,,,,,,,,,1522.17,,,percent of total billed charges,,,1773.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FLUORO GD ANDLOC NEEDLE SPINE,3221579,CDM,320,RC,77003,CPT,,,,,,inpatient,facility,,,348,146.16,295.8,334.08,,295.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.76,,,percent of total billed charges,,,,,,,,,313.2,,,percent of total billed charges,,,334.08,,,percent of total billed charges,,,330.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,323.64,,,percent of total billed charges,,,330.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FLUORO GD ANDLOC NEEDLE SPINE,3221579,CDM,320,RC,77003,CPT,,,,,,outpatient,facility,,,348,146.16,93.96,348,,295.8,,,percent of total billed charges,,,93.96,,,percent of total billed charges,,,239.42,,,percent of total billed charges,,,234.2,,,percent of total billed charges,,,294.06,,,percent of total billed charges,,,,,,,,,302.76,,,percent of total billed charges,,,302.76,,,percent of total billed charges,,,295.8,,,percent of total billed charges,,,334.08,,,percent of total billed charges,,,330.6,,,percent of total billed charges,,,,,,,,,313.2,,,percent of total billed charges,,,,,,,,,323.64,,,percent of total billed charges,,,330.6,,,percent of total billed charges,,,,,,,,,,,,,,,348,,,fee schedule,,,348,,,fee schedule,,,348,,,fee schedule,,,,,,,,,271.79,,,percent of total billed charges,,,316.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FLUORO GD PLCMT NEEDLE,3221603,CDM,320,RC,77002,CPT,,,,,,inpatient,facility,,,331,139.02,281.35,317.76,,281.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.97,,,percent of total billed charges,,,,,,,,,297.9,,,percent of total billed charges,,,317.76,,,percent of total billed charges,,,314.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,307.83,,,percent of total billed charges,,,314.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FLUORO GD PLCMT NEEDLE,3221603,CDM,320,RC,77002,CPT,,,,,,outpatient,facility,,,331,139.02,89.37,331,,281.35,,,percent of total billed charges,,,89.37,,,percent of total billed charges,,,227.73,,,percent of total billed charges,,,222.76,,,percent of total billed charges,,,279.69,,,percent of total billed charges,,,,,,,,,287.97,,,percent of total billed charges,,,287.97,,,percent of total billed charges,,,281.35,,,percent of total billed charges,,,317.76,,,percent of total billed charges,,,314.45,,,percent of total billed charges,,,,,,,,,297.9,,,percent of total billed charges,,,,,,,,,307.83,,,percent of total billed charges,,,314.45,,,percent of total billed charges,,,,,,,,,,,,,,,331,,,fee schedule,,,331,,,fee schedule,,,331,,,fee schedule,,,,,,,,,258.51,,,percent of total billed charges,,,301.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FLUORO 0 1 HR TIME PHYS QHCP,3221611,CDM,320,RC,76000,CPT,,,,,,inpatient,facility,,,553,232.26,470.05,530.88,,470.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.11,,,percent of total billed charges,,,,,,,,,497.7,,,percent of total billed charges,,,530.88,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,514.29,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FLUORO 0 1 HR TIME PHYS QHCP,3221611,CDM,320,RC,76000,CPT,,,,,,outpatient,facility,,,553,232.26,149.31,530.88,,470.05,,,percent of total billed charges,,,149.31,,,percent of total billed charges,,,380.46,,,percent of total billed charges,,,372.17,,,percent of total billed charges,,,467.28,,,percent of total billed charges,,,,,,,,,481.11,,,percent of total billed charges,,,481.11,,,percent of total billed charges,,,470.05,,,percent of total billed charges,,,530.88,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,497.7,,,percent of total billed charges,,,,,,,,,514.29,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,431.89,,,percent of total billed charges,,,503.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FLUORO 0 1 HR TIME PHYS QHCP,3221611,CDM,320,RC,76000,CPT,5523,APC,,,,outpatient,facility,,,553,553,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOOT CMP 3 PLUS VW LT,3221645,CDM,320,RC,73630,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOOT CMP 3 PLUS VW LT,3221645,CDM,320,RC,73630,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOOT CMP 3 PLUS VW LT,3221645,CDM,320,RC,73630,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOOT CMP 3 PLUS VW RT,3221652,CDM,320,RC,73630,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOOT CMP 3 PLUS VW RT,3221652,CDM,320,RC,73630,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOOT CMP 3 PLUS VW RT,3221652,CDM,320,RC,73630,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOOT 2 VW LT,3221678,CDM,320,RC,73620,CPT,,,,,LT  ,inpatient,facility,,,96,40.32,81.6,92.16,,81.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.52,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW LT,3221678,CDM,320,RC,73620,CPT,,,,,LT  ,outpatient,facility,,,96,40.32,25.92,92.73,,81.6,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,81.12,,,percent of total billed charges,,,,,,,,,83.52,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,74.98,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW LT,3221678,CDM,320,RC,73620,CPT,5521,APC,,,LT  ,outpatient,facility,,,96,96,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOOT 2 VW RT,3221686,CDM,320,RC,73620,CPT,,,,,RT  ,inpatient,facility,,,96,40.32,81.6,92.16,,81.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.52,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW RT,3221686,CDM,320,RC,73620,CPT,,,,,RT  ,outpatient,facility,,,96,40.32,25.92,92.73,,81.6,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,81.12,,,percent of total billed charges,,,,,,,,,83.52,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,74.98,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW RT,3221686,CDM,320,RC,73620,CPT,5521,APC,,,RT  ,outpatient,facility,,,96,96,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOREARM 2 VW LT,3221702,CDM,320,RC,73090,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW LT,3221702,CDM,320,RC,73090,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW LT,3221702,CDM,320,RC,73090,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOREARM 2 VW RT,3221710,CDM,320,RC,73090,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW RT,3221710,CDM,320,RC,73090,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW RT,3221710,CDM,320,RC,73090,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HAND 3 PLUS VW LT,3221744,CDM,320,RC,73130,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HAND 3 PLUS VW LT,3221744,CDM,320,RC,73130,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HAND 3 PLUS VW LT,3221744,CDM,320,RC,73130,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HAND 3 PLUS VW RT,3221751,CDM,320,RC,73130,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HAND 3 PLUS VW RT,3221751,CDM,320,RC,73130,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HAND 3 PLUS VW RT,3221751,CDM,320,RC,73130,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HAND 2 VW LT,3221777,CDM,320,RC,73120,CPT,,,,,LT  ,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW LT,3221777,CDM,320,RC,73120,CPT,,,,,LT  ,outpatient,facility,,,97,40.74,26.19,112.19,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW LT,3221777,CDM,320,RC,73120,CPT,5522,APC,,,LT  ,outpatient,facility,,,97,97,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HAND 2 VW RT,3221785,CDM,320,RC,73120,CPT,,,,,RT  ,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW RT,3221785,CDM,320,RC,73120,CPT,,,,,RT  ,outpatient,facility,,,97,40.74,26.19,112.19,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW RT,3221785,CDM,320,RC,73120,CPT,5522,APC,,,RT  ,outpatient,facility,,,97,97,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HUMERUS 2 PLUS VW LT,3221876,CDM,320,RC,73060,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 PLUS VW LT,3221876,CDM,320,RC,73060,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 PLUS VW LT,3221876,CDM,320,RC,73060,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HUMERUS 2 PLUS VW RT,3221884,CDM,320,RC,73060,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 PLUS VW RT,3221884,CDM,320,RC,73060,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 PLUS VW RT,3221884,CDM,320,RC,73060,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
HYSTEROSALPINGOGRAM S ANDI,3221892,CDM,320,RC,74740,CPT,,,,,,inpatient,facility,,,691,290.22,587.35,663.36,,587.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,601.17,,,percent of total billed charges,,,,,,,,,621.9,,,percent of total billed charges,,,663.36,,,percent of total billed charges,,,656.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,642.63,,,percent of total billed charges,,,656.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
HYSTEROSALPINGOGRAM S ANDI,3221892,CDM,320,RC,74740,CPT,,,,,,outpatient,facility,,,691,290.22,186.57,663.36,,587.35,,,percent of total billed charges,,,186.57,,,percent of total billed charges,,,475.41,,,percent of total billed charges,,,465.04,,,percent of total billed charges,,,583.89,,,percent of total billed charges,,,,,,,,,601.17,,,percent of total billed charges,,,601.17,,,percent of total billed charges,,,587.35,,,percent of total billed charges,,,663.36,,,percent of total billed charges,,,656.45,,,percent of total billed charges,,,,,,,,,621.9,,,percent of total billed charges,,,,,,,,,642.63,,,percent of total billed charges,,,656.45,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,539.67,,,percent of total billed charges,,,628.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
HYSTEROSALPINGOGRAM S ANDI,3221892,CDM,320,RC,74740,CPT,5523,APC,,,,outpatient,facility,,,691,691,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ CNT ABSC CYST VIA PREV CATH TB,3221942,CDM,361,RC,49424,CPT,,,,,,inpatient,facility,,,743,312.06,631.55,713.28,,631.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.41,,,percent of total billed charges,,,,,,,,,668.7,,,percent of total billed charges,,,713.28,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,690.99,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CNT ABSC CYST VIA PREV CATH TB,3221942,CDM,361,RC,49424,CPT,,,,,,outpatient,facility,,,743,312.06,200.61,3428,,631.55,,,percent of total billed charges,,,200.61,,,percent of total billed charges,,,511.18,,,percent of total billed charges,,,500.04,,,percent of total billed charges,,,627.84,,,percent of total billed charges,,,,,,,,,646.41,,,percent of total billed charges,,,646.41,,,percent of total billed charges,,,631.55,,,percent of total billed charges,,,713.28,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,668.7,,,percent of total billed charges,,,,,,,,,690.99,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,,,,,,,743,,,fee schedule,,,743,,,fee schedule,,,743,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,676.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ CYSTOGRAM,3222239,CDM,361,RC,51600,CPT,,,,,,inpatient,facility,,,784,329.28,666.4,752.64,,666.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.08,,,percent of total billed charges,,,,,,,,,705.6,,,percent of total billed charges,,,752.64,,,percent of total billed charges,,,744.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,729.12,,,percent of total billed charges,,,744.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CYSTOGRAM,3222239,CDM,361,RC,51600,CPT,,,,,,outpatient,facility,,,784,329.28,211.68,3428,,666.4,,,percent of total billed charges,,,211.68,,,percent of total billed charges,,,539.39,,,percent of total billed charges,,,527.63,,,percent of total billed charges,,,662.48,,,percent of total billed charges,,,,,,,,,682.08,,,percent of total billed charges,,,682.08,,,percent of total billed charges,,,666.4,,,percent of total billed charges,,,752.64,,,percent of total billed charges,,,744.8,,,percent of total billed charges,,,,,,,,,705.6,,,percent of total billed charges,,,,,,,,,729.12,,,percent of total billed charges,,,744.8,,,percent of total billed charges,,,,,,,,,,,,,,,784,,,fee schedule,,,784,,,fee schedule,,,784,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,713.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ DISCOGRAM CERVICAL THORACIC,3222247,CDM,361,RC,62291,CPT,,,,,,inpatient,facility,,,1676,703.92,1424.6,1608.96,,1424.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1458.12,,,percent of total billed charges,,,,,,,,,1508.4,,,percent of total billed charges,,,1608.96,,,percent of total billed charges,,,1592.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1558.68,,,percent of total billed charges,,,1592.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ DISCOGRAM CERVICAL THORACIC,3222247,CDM,361,RC,62291,CPT,,,,,,outpatient,facility,,,1676,703.92,452.52,3428,,1424.6,,,percent of total billed charges,,,452.52,,,percent of total billed charges,,,1153.09,,,percent of total billed charges,,,1127.95,,,percent of total billed charges,,,1416.22,,,percent of total billed charges,,,,,,,,,1458.12,,,percent of total billed charges,,,1458.12,,,percent of total billed charges,,,1424.6,,,percent of total billed charges,,,1608.96,,,percent of total billed charges,,,1592.2,,,percent of total billed charges,,,,,,,,,1508.4,,,percent of total billed charges,,,,,,,,,1558.68,,,percent of total billed charges,,,1592.2,,,percent of total billed charges,,,,,,,,,,,,,,,1676,,,fee schedule,,,1676,,,fee schedule,,,1676,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1525.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ DISCOGRAM LUMBAR,3222254,CDM,361,RC,62290,CPT,,,,,,inpatient,facility,,,1727,725.34,1467.95,1657.92,,1467.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1502.49,,,percent of total billed charges,,,,,,,,,1554.3,,,percent of total billed charges,,,1657.92,,,percent of total billed charges,,,1640.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1606.11,,,percent of total billed charges,,,1640.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ DISCOGRAM LUMBAR,3222254,CDM,361,RC,62290,CPT,,,,,,outpatient,facility,,,1727,725.34,466.29,3428,,1467.95,,,percent of total billed charges,,,466.29,,,percent of total billed charges,,,1188.18,,,percent of total billed charges,,,1162.27,,,percent of total billed charges,,,1459.32,,,percent of total billed charges,,,,,,,,,1502.49,,,percent of total billed charges,,,1502.49,,,percent of total billed charges,,,1467.95,,,percent of total billed charges,,,1657.92,,,percent of total billed charges,,,1640.65,,,percent of total billed charges,,,,,,,,,1554.3,,,percent of total billed charges,,,,,,,,,1606.11,,,percent of total billed charges,,,1640.65,,,percent of total billed charges,,,,,,,,,,,,,,,1727,,,fee schedule,,,1727,,,fee schedule,,,1727,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1571.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ EPID PATCH BLOOD CLOT,3222288,CDM,361,RC,62273,CPT,,,,,,inpatient,facility,,,689,289.38,585.65,661.44,,585.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,599.43,,,percent of total billed charges,,,,,,,,,620.1,,,percent of total billed charges,,,661.44,,,percent of total billed charges,,,654.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,640.77,,,percent of total billed charges,,,654.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ EPID PATCH BLOOD CLOT,3222288,CDM,361,RC,62273,CPT,,,,,,outpatient,facility,,,689,289.38,186.03,3522,,585.65,,,percent of total billed charges,,,186.03,,,percent of total billed charges,,,474.03,,,percent of total billed charges,,,463.7,,,percent of total billed charges,,,582.2,,,percent of total billed charges,,,,,,,,,599.43,,,percent of total billed charges,,,599.43,,,percent of total billed charges,,,585.65,,,percent of total billed charges,,,661.44,,,percent of total billed charges,,,654.55,,,percent of total billed charges,,,,,,,,,620.1,,,percent of total billed charges,,,,,,,,,640.77,,,percent of total billed charges,,,654.55,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,626.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ EPID PATCH BLOOD CLOT,3222288,CDM,361,RC,62273,CPT,5442,APC,,,,outpatient,facility,,,689,689,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S TRIGGER PT S MUSC S 1 2,3222536,CDM,361,RC,20552,CPT,,,,,,inpatient,facility,,,531,223.02,451.35,509.76,,451.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.97,,,percent of total billed charges,,,,,,,,,477.9,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,493.83,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S TRIGGER PT S MUSC S 1 2,3222536,CDM,361,RC,20552,CPT,,,,,,outpatient,facility,,,531,223.02,143.37,3428,,451.35,,,percent of total billed charges,,,143.37,,,percent of total billed charges,,,365.33,,,percent of total billed charges,,,357.36,,,percent of total billed charges,,,448.69,,,percent of total billed charges,,,,,,,,,461.97,,,percent of total billed charges,,,461.97,,,percent of total billed charges,,,451.35,,,percent of total billed charges,,,509.76,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,,,,,,,,477.9,,,percent of total billed charges,,,,,,,,,493.83,,,percent of total billed charges,,,504.45,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,483.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S TRIGGER PT S MUSC S 1 2,3222536,CDM,361,RC,20552,CPT,5441,APC,,,,outpatient,facility,,,531,531,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S TRIGGER PT S MUSC S 3 PLUS,3222601,CDM,361,RC,20553,CPT,,,,,,inpatient,facility,,,603,253.26,512.55,578.88,,512.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,524.61,,,percent of total billed charges,,,,,,,,,542.7,,,percent of total billed charges,,,578.88,,,percent of total billed charges,,,572.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,560.79,,,percent of total billed charges,,,572.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S TRIGGER PT S MUSC S 3 PLUS,3222601,CDM,361,RC,20553,CPT,,,,,,outpatient,facility,,,603,253.26,162.81,3428,,512.55,,,percent of total billed charges,,,162.81,,,percent of total billed charges,,,414.86,,,percent of total billed charges,,,405.82,,,percent of total billed charges,,,509.53,,,percent of total billed charges,,,,,,,,,524.61,,,percent of total billed charges,,,524.61,,,percent of total billed charges,,,512.55,,,percent of total billed charges,,,578.88,,,percent of total billed charges,,,572.85,,,percent of total billed charges,,,,,,,,,542.7,,,percent of total billed charges,,,,,,,,,560.79,,,percent of total billed charges,,,572.85,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,548.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S TRIGGER PT S MUSC S 3 PLUS,3222601,CDM,361,RC,20553,CPT,5441,APC,,,,outpatient,facility,,,603,603,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ PSEUDOANEURYSM EXT LT,3222619,CDM,361,RC,36002,CPT,,,,,LT  ,inpatient,facility,,,569,238.98,483.65,546.24,,483.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.03,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ PSEUDOANEURYSM EXT LT,3222619,CDM,361,RC,36002,CPT,,,,,LT  ,outpatient,facility,,,569,238.98,153.63,3522,,483.65,,,percent of total billed charges,,,153.63,,,percent of total billed charges,,,391.47,,,percent of total billed charges,,,382.94,,,percent of total billed charges,,,480.81,,,percent of total billed charges,,,,,,,,,495.03,,,percent of total billed charges,,,495.03,,,percent of total billed charges,,,483.65,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,517.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ PSEUDOANEURYSM EXT LT,3222619,CDM,361,RC,36002,CPT,5181,APC,,,LT  ,outpatient,facility,,,569,569,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ PSEUDOANEURYSM EXT RT,3222627,CDM,361,RC,36002,CPT,,,,,RT  ,inpatient,facility,,,569,238.98,483.65,546.24,,483.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.03,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ PSEUDOANEURYSM EXT RT,3222627,CDM,361,RC,36002,CPT,,,,,RT  ,outpatient,facility,,,569,238.98,153.63,3522,,483.65,,,percent of total billed charges,,,153.63,,,percent of total billed charges,,,391.47,,,percent of total billed charges,,,382.94,,,percent of total billed charges,,,480.81,,,percent of total billed charges,,,,,,,,,495.03,,,percent of total billed charges,,,495.03,,,percent of total billed charges,,,483.65,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,517.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ PSEUDOANEURYSM EXT RT,3222627,CDM,361,RC,36002,CPT,5181,APC,,,RT  ,outpatient,facility,,,569,569,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ URETHROCYSTOGRAM RETROGRADE,3222643,CDM,361,RC,51610,CPT,,,,,,inpatient,facility,,,393,165.06,334.05,377.28,,334.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,341.91,,,percent of total billed charges,,,,,,,,,353.7,,,percent of total billed charges,,,377.28,,,percent of total billed charges,,,373.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,365.49,,,percent of total billed charges,,,373.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ URETHROCYSTOGRAM RETROGRADE,3222643,CDM,361,RC,51610,CPT,,,,,,outpatient,facility,,,393,165.06,106.11,3428,,334.05,,,percent of total billed charges,,,106.11,,,percent of total billed charges,,,270.38,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,332.08,,,percent of total billed charges,,,,,,,,,341.91,,,percent of total billed charges,,,341.91,,,percent of total billed charges,,,334.05,,,percent of total billed charges,,,377.28,,,percent of total billed charges,,,373.35,,,percent of total billed charges,,,,,,,,,353.7,,,percent of total billed charges,,,,,,,,,365.49,,,percent of total billed charges,,,373.35,,,percent of total billed charges,,,,,,,,,,,,,,,393,,,fee schedule,,,393,,,fee schedule,,,393,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,357.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ VENOGRAM NON EXTREMITY,3222650,CDM,361,RC,36299,CPT,,,,,,inpatient,facility,,,1036,435.12,880.6,994.56,,880.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,901.32,,,percent of total billed charges,,,,,,,,,932.4,,,percent of total billed charges,,,994.56,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,963.48,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ VENOGRAM NON EXTREMITY,3222650,CDM,361,RC,36299,CPT,,,,,,outpatient,facility,,,1036,435.12,279.72,3428,,880.6,,,percent of total billed charges,,,279.72,,,percent of total billed charges,,,712.77,,,percent of total billed charges,,,697.23,,,percent of total billed charges,,,875.42,,,percent of total billed charges,,,,,,,,,901.32,,,percent of total billed charges,,,901.32,,,percent of total billed charges,,,880.6,,,percent of total billed charges,,,994.56,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,932.4,,,percent of total billed charges,,,,,,,,,963.48,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,1036,,,fee schedule,,,1036,,,fee schedule,,,1036,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,942.76,,,percent of total billed charges,,,,,,,,,,,,,,,725.2,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ VISUAL ILEAL CONDUIT,3222692,CDM,361,RC,50690,CPT,,,,,,inpatient,facility,,,3674,1543.08,3122.9,3527.04,,3122.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3196.38,,,percent of total billed charges,,,,,,,,,3306.6,,,percent of total billed charges,,,3527.04,,,percent of total billed charges,,,3490.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3416.82,,,percent of total billed charges,,,3490.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ VISUAL ILEAL CONDUIT,3222692,CDM,361,RC,50690,CPT,,,,,,outpatient,facility,,,3674,1543.08,991.98,3674,,3122.9,,,percent of total billed charges,,,991.98,,,percent of total billed charges,,,2527.71,,,percent of total billed charges,,,2472.6,,,percent of total billed charges,,,3104.53,,,percent of total billed charges,,,,,,,,,3196.38,,,percent of total billed charges,,,3196.38,,,percent of total billed charges,,,3122.9,,,percent of total billed charges,,,3527.04,,,percent of total billed charges,,,3490.3,,,percent of total billed charges,,,,,,,,,3306.6,,,percent of total billed charges,,,,,,,,,3416.82,,,percent of total billed charges,,,3490.3,,,percent of total billed charges,,,,,,,,,,,,,,,3674,,,fee schedule,,,3674,,,fee schedule,,,3674,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3343.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP BLADDER W INS CATH SUPRAPUBIC,3222759,CDM,361,RC,51102,CPT,,,,,,inpatient,facility,,,3760,1579.2,3196,3609.6,,3196,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3271.2,,,percent of total billed charges,,,,,,,,,3384,,,percent of total billed charges,,,3609.6,,,percent of total billed charges,,,3572,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3496.8,,,percent of total billed charges,,,3572,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP BLADDER W INS CATH SUPRAPUBIC,3222759,CDM,361,RC,51102,CPT,,,,,,outpatient,facility,,,3760,1579.2,1015.2,11510,,3196,,,percent of total billed charges,,,1015.2,,,percent of total billed charges,,,2586.88,,,percent of total billed charges,,,2530.48,,,percent of total billed charges,,,3177.2,,,percent of total billed charges,,,,,,,,,3271.2,,,percent of total billed charges,,,3271.2,,,percent of total billed charges,,,3196,,,percent of total billed charges,,,3609.6,,,percent of total billed charges,,,3572,,,percent of total billed charges,,,,,,,,,3384,,,percent of total billed charges,,,,,,,,,3496.8,,,percent of total billed charges,,,3572,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3421.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP BLADDER W INS CATH SUPRAPUBIC,3222759,CDM,361,RC,51102,CPT,5373,APC,,,,outpatient,facility,,,3760,3760,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS TIPS,3222775,CDM,361,RC,37182,CPT,,,,,,inpatient,facility,,,14504,6091.68,12328.4,13923.84,,12328.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12618.48,,,percent of total billed charges,,,,,,,,,13053.6,,,percent of total billed charges,,,13923.84,,,percent of total billed charges,,,13778.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13488.72,,,percent of total billed charges,,,13778.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS TIPS,3222775,CDM,361,RC,37182,CPT,,,,,,outpatient,facility,,,14504,6091.68,3916.08,29580,,12328.4,,,percent of total billed charges,,,3916.08,,,percent of total billed charges,,,9978.75,,,percent of total billed charges,,,9761.19,,,percent of total billed charges,,,12255.88,,,percent of total billed charges,,,,,,,,,12618.48,,,percent of total billed charges,,,12618.48,,,percent of total billed charges,,,12328.4,,,percent of total billed charges,,,13923.84,,,percent of total billed charges,,,13778.8,,,percent of total billed charges,,,,,,,,,13053.6,,,percent of total billed charges,,,,,,,,,13488.72,,,percent of total billed charges,,,13778.8,,,percent of total billed charges,,,,,,,,,,,,,,,14504,,,fee schedule,,,14504,,,fee schedule,,,14504,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,13198.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS CATH BLADDER INDWL SMPL,3222783,CDM,361,RC,51702,CPT,,,,,,inpatient,facility,,,228,95.76,193.8,218.88,,193.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,198.36,,,percent of total billed charges,,,,,,,,,205.2,,,percent of total billed charges,,,218.88,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,212.04,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS CATH BLADDER INDWL SMPL,3222783,CDM,361,RC,51702,CPT,,,,,,outpatient,facility,,,228,95.76,61.56,3428,,193.8,,,percent of total billed charges,,,61.56,,,percent of total billed charges,,,156.86,,,percent of total billed charges,,,153.44,,,percent of total billed charges,,,192.66,,,percent of total billed charges,,,,,,,,,198.36,,,percent of total billed charges,,,198.36,,,percent of total billed charges,,,193.8,,,percent of total billed charges,,,218.88,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,,,,,,,205.2,,,percent of total billed charges,,,,,,,,,212.04,,,percent of total billed charges,,,216.6,,,percent of total billed charges,,,,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,127.74,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,207.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS CATH BLADDER INDWL SMPL,3222783,CDM,361,RC,51702,CPT,5734,APC,,,,outpatient,facility,,,228,228,63.07,189.01,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,132.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,130.35,,,fee schedule,,,,,,,,,,,,,,,189.01,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",175.97,,,fee schedule,,,,,,,,,,,,,,,,,,,,,130.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,130.35,,,fee schedule,,,130.35,,,fee schedule,,,63.07,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INTRO TUBE GI LONG W FLUORO S ANDI,3222841,CDM,320,RC,74340,CPT,,,,,,inpatient,facility,,,297,124.74,252.45,285.12,,252.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.39,,,percent of total billed charges,,,,,,,,,267.3,,,percent of total billed charges,,,285.12,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,276.21,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO TUBE GI LONG W FLUORO S ANDI,3222841,CDM,320,RC,74340,CPT,,,,,,outpatient,facility,,,297,124.74,80.19,297,,252.45,,,percent of total billed charges,,,80.19,,,percent of total billed charges,,,204.34,,,percent of total billed charges,,,199.88,,,percent of total billed charges,,,250.97,,,percent of total billed charges,,,,,,,,,258.39,,,percent of total billed charges,,,258.39,,,percent of total billed charges,,,252.45,,,percent of total billed charges,,,285.12,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,,,,,,,,267.3,,,percent of total billed charges,,,,,,,,,276.21,,,percent of total billed charges,,,282.15,,,percent of total billed charges,,,,,,,,,,,,,,,297,,,fee schedule,,,297,,,fee schedule,,,297,,,fee schedule,,,,,,,,,231.96,,,percent of total billed charges,,,270.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO CATH AORTA,3222866,CDM,361,RC,36200,CPT,,,,,,inpatient,facility,,,1614,677.88,1371.9,1549.44,,1371.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1404.18,,,percent of total billed charges,,,,,,,,,1452.6,,,percent of total billed charges,,,1549.44,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1501.02,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO CATH AORTA,3222866,CDM,361,RC,36200,CPT,,,,,,outpatient,facility,,,1614,677.88,435.78,3428,,1371.9,,,percent of total billed charges,,,435.78,,,percent of total billed charges,,,1110.43,,,percent of total billed charges,,,1086.22,,,percent of total billed charges,,,1363.83,,,percent of total billed charges,,,,,,,,,1404.18,,,percent of total billed charges,,,1404.18,,,percent of total billed charges,,,1371.9,,,percent of total billed charges,,,1549.44,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,1452.6,,,percent of total billed charges,,,,,,,,,1501.02,,,percent of total billed charges,,,1533.3,,,percent of total billed charges,,,,,,,,,,,,,,,1614,,,fee schedule,,,1614,,,fee schedule,,,1614,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1468.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO CATH RT HEART ART PULM MAIN,3222908,CDM,361,RC,36013,CPT,,,,,,inpatient,facility,,,313,131.46,266.05,300.48,,266.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,272.31,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO CATH RT HEART ART PULM MAIN,3222908,CDM,361,RC,36013,CPT,,,,,,outpatient,facility,,,313,131.46,84.51,3428,,266.05,,,percent of total billed charges,,,84.51,,,percent of total billed charges,,,215.34,,,percent of total billed charges,,,210.65,,,percent of total billed charges,,,264.49,,,percent of total billed charges,,,,,,,,,272.31,,,percent of total billed charges,,,272.31,,,percent of total billed charges,,,266.05,,,percent of total billed charges,,,300.48,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,281.7,,,percent of total billed charges,,,,,,,,,291.09,,,percent of total billed charges,,,297.35,,,percent of total billed charges,,,,,,,,,,,,,,,313,,,fee schedule,,,313,,,fee schedule,,,313,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,284.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO CATH SVC IVC,3222916,CDM,361,RC,36010,CPT,,,,,,inpatient,facility,,,1796,754.32,1526.6,1724.16,,1526.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1562.52,,,percent of total billed charges,,,,,,,,,1616.4,,,percent of total billed charges,,,1724.16,,,percent of total billed charges,,,1706.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1670.28,,,percent of total billed charges,,,1706.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO CATH SVC IVC,3222916,CDM,361,RC,36010,CPT,,,,,,outpatient,facility,,,1796,754.32,484.92,3428,,1526.6,,,percent of total billed charges,,,484.92,,,percent of total billed charges,,,1235.65,,,percent of total billed charges,,,1208.71,,,percent of total billed charges,,,1517.62,,,percent of total billed charges,,,,,,,,,1562.52,,,percent of total billed charges,,,1562.52,,,percent of total billed charges,,,1526.6,,,percent of total billed charges,,,1724.16,,,percent of total billed charges,,,1706.2,,,percent of total billed charges,,,,,,,,,1616.4,,,percent of total billed charges,,,,,,,,,1670.28,,,percent of total billed charges,,,1706.2,,,percent of total billed charges,,,,,,,,,,,,,,,1796,,,fee schedule,,,1796,,,fee schedule,,,1796,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1634.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO TUBE GI LONG,3222957,CDM,361,RC,44500,CPT,,,,,,inpatient,facility,,,1282,538.44,1089.7,1230.72,,1089.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1115.34,,,percent of total billed charges,,,,,,,,,1153.8,,,percent of total billed charges,,,1230.72,,,percent of total billed charges,,,1217.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1192.26,,,percent of total billed charges,,,1217.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO TUBE GI LONG,3222957,CDM,361,RC,44500,CPT,,,,,,outpatient,facility,,,1282,538.44,346.14,5933,,1089.7,,,percent of total billed charges,,,346.14,,,percent of total billed charges,,,882.02,,,percent of total billed charges,,,862.79,,,percent of total billed charges,,,1083.29,,,percent of total billed charges,,,,,,,,,1115.34,,,percent of total billed charges,,,1115.34,,,percent of total billed charges,,,1089.7,,,percent of total billed charges,,,1230.72,,,percent of total billed charges,,,1217.9,,,percent of total billed charges,,,,,,,,,1153.8,,,percent of total billed charges,,,,,,,,,1192.26,,,percent of total billed charges,,,1217.9,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1166.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO TUBE GI LONG,3222957,CDM,361,RC,44500,CPT,5301,APC,,,,outpatient,facility,,,1282,1282,448.42,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,448.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INTRO NDL CATH ARTERY EXTREMITY LT,3223005,CDM,361,RC,36140,CPT,,,,,LT  ,inpatient,facility,,,1855,779.1,1576.75,1780.8,,1576.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1613.85,,,percent of total billed charges,,,,,,,,,1669.5,,,percent of total billed charges,,,1780.8,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1725.15,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO NDL CATH ARTERY EXTREMITY LT,3223005,CDM,361,RC,36140,CPT,,,,,LT  ,outpatient,facility,,,1855,779.1,500.85,3428,,1576.75,,,percent of total billed charges,,,500.85,,,percent of total billed charges,,,1276.24,,,percent of total billed charges,,,1248.41,,,percent of total billed charges,,,1567.47,,,percent of total billed charges,,,,,,,,,1613.85,,,percent of total billed charges,,,1613.85,,,percent of total billed charges,,,1576.75,,,percent of total billed charges,,,1780.8,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,1669.5,,,percent of total billed charges,,,,,,,,,1725.15,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,,,,,,,1855,,,fee schedule,,,1855,,,fee schedule,,,1855,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1688.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INTRO NDL CATH ARTERY EXTREMITY RT,3223013,CDM,361,RC,36140,CPT,,,,,RT  ,inpatient,facility,,,1855,779.1,1576.75,1780.8,,1576.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1613.85,,,percent of total billed charges,,,,,,,,,1669.5,,,percent of total billed charges,,,1780.8,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1725.15,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO NDL CATH ARTERY EXTREMITY RT,3223013,CDM,361,RC,36140,CPT,,,,,RT  ,outpatient,facility,,,1855,779.1,500.85,3428,,1576.75,,,percent of total billed charges,,,500.85,,,percent of total billed charges,,,1276.24,,,percent of total billed charges,,,1248.41,,,percent of total billed charges,,,1567.47,,,percent of total billed charges,,,,,,,,,1613.85,,,percent of total billed charges,,,1613.85,,,percent of total billed charges,,,1576.75,,,percent of total billed charges,,,1780.8,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,1669.5,,,percent of total billed charges,,,,,,,,,1725.15,,,percent of total billed charges,,,1762.25,,,percent of total billed charges,,,,,,,,,,,,,,,1855,,,fee schedule,,,1855,,,fee schedule,,,1855,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1688.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
UROGRAPHY INF AND BOLUS W NEPHRO,3223039,CDM,320,RC,74415,CPT,,,,,,inpatient,facility,,,1292,542.64,1098.2,1240.32,,1098.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1124.04,,,percent of total billed charges,,,,,,,,,1162.8,,,percent of total billed charges,,,1240.32,,,percent of total billed charges,,,1227.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1201.56,,,percent of total billed charges,,,1227.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
UROGRAPHY INF AND BOLUS W NEPHRO,3223039,CDM,320,RC,74415,CPT,,,,,,outpatient,facility,,,1292,542.64,183.74,1240.32,,1098.2,,,percent of total billed charges,,,348.84,,,percent of total billed charges,,,888.9,,,percent of total billed charges,,,869.52,,,percent of total billed charges,,,1091.74,,,percent of total billed charges,,,,,,,,,1124.04,,,percent of total billed charges,,,1124.04,,,percent of total billed charges,,,1098.2,,,percent of total billed charges,,,1240.32,,,percent of total billed charges,,,1227.4,,,percent of total billed charges,,,,,,,,,1162.8,,,percent of total billed charges,,,,,,,,,1201.56,,,percent of total billed charges,,,1227.4,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1009.05,,,percent of total billed charges,,,1175.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
UROGRAPHY INF AND BOLUS W NEPHRO,3223039,CDM,320,RC,74415,CPT,5571,APC,,,,outpatient,facility,,,1292,1292,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
UROGRAPHY IV W WO KUB,3223047,CDM,320,RC,74400,CPT,,,,,,inpatient,facility,,,1059,444.78,900.15,1016.64,,900.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,921.33,,,percent of total billed charges,,,,,,,,,953.1,,,percent of total billed charges,,,1016.64,,,percent of total billed charges,,,1006.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,984.87,,,percent of total billed charges,,,1006.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
UROGRAPHY IV W WO KUB,3223047,CDM,320,RC,74400,CPT,,,,,,outpatient,facility,,,1059,444.78,183.74,1016.64,,900.15,,,percent of total billed charges,,,285.93,,,percent of total billed charges,,,728.59,,,percent of total billed charges,,,712.71,,,percent of total billed charges,,,894.86,,,percent of total billed charges,,,,,,,,,921.33,,,percent of total billed charges,,,921.33,,,percent of total billed charges,,,900.15,,,percent of total billed charges,,,1016.64,,,percent of total billed charges,,,1006.05,,,percent of total billed charges,,,,,,,,,953.1,,,percent of total billed charges,,,,,,,,,984.87,,,percent of total billed charges,,,1006.05,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,827.08,,,percent of total billed charges,,,963.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
UROGRAPHY IV W WO KUB,3223047,CDM,320,RC,74400,CPT,5571,APC,,,,outpatient,facility,,,1059,1059,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
APPLY MANUAL STRESS JOINT UNI BI,3223096,CDM,320,RC,77071,CPT,,,,,,inpatient,facility,,,237,99.54,201.45,227.52,,201.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.19,,,percent of total billed charges,,,,,,,,,213.3,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
APPLY MANUAL STRESS JOINT UNI BI,3223096,CDM,320,RC,77071,CPT,,,,,,outpatient,facility,,,237,99.54,63.99,227.52,,201.45,,,percent of total billed charges,,,63.99,,,percent of total billed charges,,,163.06,,,percent of total billed charges,,,159.5,,,percent of total billed charges,,,200.26,,,percent of total billed charges,,,,,,,,,206.19,,,percent of total billed charges,,,206.19,,,percent of total billed charges,,,201.45,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,213.3,,,percent of total billed charges,,,,,,,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,185.1,,,percent of total billed charges,,,215.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
APPLY MANUAL STRESS JOINT UNI BI,3223096,CDM,320,RC,77071,CPT,5521,APC,,,,outpatient,facility,,,237,237,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
SURVEY JOINT SGL VW 2 PLUS JTS,3223104,CDM,320,RC,77077,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SURVEY JOINT SGL VW 2 PLUS JTS,3223104,CDM,320,RC,77077,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SURVEY JOINT SGL VW 2 PLUS JTS,3223104,CDM,320,RC,77077,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR KNEE CMP 4 PLUS VW LT,3223120,CDM,320,RC,73564,CPT,,,,,LT  ,inpatient,facility,,,123,51.66,104.55,118.08,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.01,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR KNEE CMP 4 PLUS VW LT,3223120,CDM,320,RC,73564,CPT,,,,,LT  ,outpatient,facility,,,123,51.66,33.21,118.08,,104.55,,,percent of total billed charges,,,33.21,,,percent of total billed charges,,,84.62,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,103.94,,,percent of total billed charges,,,,,,,,,107.01,,,percent of total billed charges,,,107.01,,,percent of total billed charges,,,104.55,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,96.06,,,percent of total billed charges,,,111.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR KNEE CMP 4 PLUS VW LT,3223120,CDM,320,RC,73564,CPT,5522,APC,,,LT  ,outpatient,facility,,,123,123,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR KNEE CMP 4 PLUS VW RT,3223138,CDM,320,RC,73564,CPT,,,,,RT  ,inpatient,facility,,,123,51.66,104.55,118.08,,104.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,107.01,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR KNEE CMP 4 PLUS VW RT,3223138,CDM,320,RC,73564,CPT,,,,,RT  ,outpatient,facility,,,123,51.66,33.21,118.08,,104.55,,,percent of total billed charges,,,33.21,,,percent of total billed charges,,,84.62,,,percent of total billed charges,,,82.78,,,percent of total billed charges,,,103.94,,,percent of total billed charges,,,,,,,,,107.01,,,percent of total billed charges,,,107.01,,,percent of total billed charges,,,104.55,,,percent of total billed charges,,,118.08,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,110.7,,,percent of total billed charges,,,,,,,,,114.39,,,percent of total billed charges,,,116.85,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,96.06,,,percent of total billed charges,,,111.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR KNEE CMP 4 PLUS VW RT,3223138,CDM,320,RC,73564,CPT,5522,APC,,,RT  ,outpatient,facility,,,123,123,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR KNEE 1 2 VW LT,3223153,CDM,320,RC,73560,CPT,,,,,LT  ,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR KNEE 1 2 VW LT,3223153,CDM,320,RC,73560,CPT,,,,,LT  ,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR KNEE 1 2 VW LT,3223153,CDM,320,RC,73560,CPT,5521,APC,,,LT  ,outpatient,facility,,,97,97,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR KNEE 1 2 VW RT,3223161,CDM,320,RC,73560,CPT,,,,,RT  ,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR KNEE 1 2 VW RT,3223161,CDM,320,RC,73560,CPT,,,,,RT  ,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR KNEE 1 2 VW RT,3223161,CDM,320,RC,73560,CPT,5521,APC,,,RT  ,outpatient,facility,,,97,97,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR KNEE 3 VW LT,3223187,CDM,320,RC,73562,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR KNEE 3 VW LT,3223187,CDM,320,RC,73562,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR KNEE 3 VW LT,3223187,CDM,320,RC,73562,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR KNEE 3 VW RT,3223195,CDM,320,RC,73562,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR KNEE 3 VW RT,3223195,CDM,320,RC,73562,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR KNEE 3 VW RT,3223195,CDM,320,RC,73562,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR KNEES STANDING AP BI,3223203,CDM,320,RC,73565,CPT,,,,,,inpatient,facility,,,167,70.14,141.95,160.32,,141.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,145.29,,,percent of total billed charges,,,,,,,,,150.3,,,percent of total billed charges,,,160.32,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,155.31,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR KNEES STANDING AP BI,3223203,CDM,320,RC,73565,CPT,,,,,,outpatient,facility,,,167,70.14,45.09,160.32,,141.95,,,percent of total billed charges,,,45.09,,,percent of total billed charges,,,114.9,,,percent of total billed charges,,,112.39,,,percent of total billed charges,,,141.12,,,percent of total billed charges,,,,,,,,,145.29,,,percent of total billed charges,,,145.29,,,percent of total billed charges,,,141.95,,,percent of total billed charges,,,160.32,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,150.3,,,percent of total billed charges,,,,,,,,,155.31,,,percent of total billed charges,,,158.65,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,130.43,,,percent of total billed charges,,,151.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR KNEES STANDING AP BI,3223203,CDM,320,RC,73565,CPT,5521,APC,,,,outpatient,facility,,,167,167,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR EXT LOWER INFANT 2 PLUS VW LT,3223229,CDM,320,RC,73592,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR EXT LOWER INFANT 2 PLUS VW LT,3223229,CDM,320,RC,73592,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR EXT LOWER INFANT 2 PLUS VW LT,3223229,CDM,320,RC,73592,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR EXT LOWER INFANT 2 PLUS VW RT,3223237,CDM,320,RC,73592,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR EXT LOWER INFANT 2 PLUS VW RT,3223237,CDM,320,RC,73592,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR EXT LOWER INFANT 2 PLUS VW RT,3223237,CDM,320,RC,73592,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PUNCT LUMBAR DIAGNOSTIC,3223252,CDM,361,RC,62270,CPT,,,,,,inpatient,facility,,,1047,439.74,889.95,1005.12,,889.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.89,,,percent of total billed charges,,,,,,,,,942.3,,,percent of total billed charges,,,1005.12,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,973.71,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCT LUMBAR DIAGNOSTIC,3223252,CDM,361,RC,62270,CPT,,,,,,outpatient,facility,,,1047,439.74,282.69,3522,,889.95,,,percent of total billed charges,,,282.69,,,percent of total billed charges,,,720.34,,,percent of total billed charges,,,704.63,,,percent of total billed charges,,,884.71,,,percent of total billed charges,,,,,,,,,910.89,,,percent of total billed charges,,,910.89,,,percent of total billed charges,,,889.95,,,percent of total billed charges,,,1005.12,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,942.3,,,percent of total billed charges,,,,,,,,,973.71,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,952.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCT LUMBAR DIAGNOSTIC,3223252,CDM,361,RC,62270,CPT,5442,APC,,,,outpatient,facility,,,1047,1047,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR MANDIBLE CMP 4 PLUS VW,3223336,CDM,320,RC,70110,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR MANDIBLE CMP 4 PLUS VW,3223336,CDM,320,RC,70110,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR MANDIBLE CMP 4 PLUS VW,3223336,CDM,320,RC,70110,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR MANDIBLE PARTIAL 1 3 VW,3223344,CDM,320,RC,70100,CPT,,,,,,inpatient,facility,,,96,40.32,81.6,92.16,,81.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.52,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR MANDIBLE PARTIAL 1 3 VW,3223344,CDM,320,RC,70100,CPT,,,,,,outpatient,facility,,,96,40.32,25.92,92.73,,81.6,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,81.12,,,percent of total billed charges,,,,,,,,,83.52,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,74.98,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR MANDIBLE PARTIAL 1 3 VW,3223344,CDM,320,RC,70100,CPT,5521,APC,,,,outpatient,facility,,,96,96,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
MYELOGRAPHY CERVICAL S ANDI,3223377,CDM,320,RC,72240,CPT,,,,,,inpatient,facility,,,1651,693.42,1403.35,1584.96,,1403.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1436.37,,,percent of total billed charges,,,,,,,,,1485.9,,,percent of total billed charges,,,1584.96,,,percent of total billed charges,,,1568.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1535.43,,,percent of total billed charges,,,1568.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY CERVICAL S ANDI,3223377,CDM,320,RC,72240,CPT,,,,,,outpatient,facility,,,1651,693.42,445.77,1584.96,,1403.35,,,percent of total billed charges,,,445.77,,,percent of total billed charges,,,1135.89,,,percent of total billed charges,,,1111.12,,,percent of total billed charges,,,1395.1,,,percent of total billed charges,,,,,,,,,1436.37,,,percent of total billed charges,,,1436.37,,,percent of total billed charges,,,1403.35,,,percent of total billed charges,,,1584.96,,,percent of total billed charges,,,1568.45,,,percent of total billed charges,,,,,,,,,1485.9,,,percent of total billed charges,,,,,,,,,1535.43,,,percent of total billed charges,,,1568.45,,,percent of total billed charges,,,,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,800.7,,,fee schedule,,,,,,,,,1289.43,,,percent of total billed charges,,,1502.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY CERVICAL S ANDI,3223377,CDM,320,RC,72240,CPT,5573,APC,,,,outpatient,facility,,,1651,1651,402.38,1184.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,1184.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1103,,,fee schedule,,,,,,,,,,,,,,,,,,,,,817.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,402.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
MYELOGRAPHY LUMBOSACRAL S ANDI,3223385,CDM,320,RC,72265,CPT,,,,,,inpatient,facility,,,1452,609.84,1234.2,1393.92,,1234.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1263.24,,,percent of total billed charges,,,,,,,,,1306.8,,,percent of total billed charges,,,1393.92,,,percent of total billed charges,,,1379.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1350.36,,,percent of total billed charges,,,1379.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY LUMBOSACRAL S ANDI,3223385,CDM,320,RC,72265,CPT,,,,,,outpatient,facility,,,1452,609.84,392.04,1393.92,,1234.2,,,percent of total billed charges,,,392.04,,,percent of total billed charges,,,998.98,,,percent of total billed charges,,,977.2,,,percent of total billed charges,,,1226.94,,,percent of total billed charges,,,,,,,,,1263.24,,,percent of total billed charges,,,1263.24,,,percent of total billed charges,,,1234.2,,,percent of total billed charges,,,1393.92,,,percent of total billed charges,,,1379.4,,,percent of total billed charges,,,,,,,,,1306.8,,,percent of total billed charges,,,,,,,,,1350.36,,,percent of total billed charges,,,1379.4,,,percent of total billed charges,,,,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,800.7,,,fee schedule,,,,,,,,,1134.01,,,percent of total billed charges,,,1321.32,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY LUMBOSACRAL S ANDI,3223385,CDM,320,RC,72265,CPT,5573,APC,,,,outpatient,facility,,,1452,1452,402.38,1184.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,1184.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1103,,,fee schedule,,,,,,,,,,,,,,,,,,,,,817.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,402.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
MYELOGRAPHY THORACIC S ANDI,3223401,CDM,320,RC,72255,CPT,,,,,,inpatient,facility,,,1525,640.5,1296.25,1464,,1296.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1326.75,,,percent of total billed charges,,,,,,,,,1372.5,,,percent of total billed charges,,,1464,,,percent of total billed charges,,,1448.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1418.25,,,percent of total billed charges,,,1448.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY THORACIC S ANDI,3223401,CDM,320,RC,72255,CPT,,,,,,outpatient,facility,,,1525,640.5,411.75,1464,,1296.25,,,percent of total billed charges,,,411.75,,,percent of total billed charges,,,1049.2,,,percent of total billed charges,,,1026.32,,,percent of total billed charges,,,1288.63,,,percent of total billed charges,,,,,,,,,1326.75,,,percent of total billed charges,,,1326.75,,,percent of total billed charges,,,1296.25,,,percent of total billed charges,,,1464,,,percent of total billed charges,,,1448.75,,,percent of total billed charges,,,,,,,,,1372.5,,,percent of total billed charges,,,,,,,,,1418.25,,,percent of total billed charges,,,1448.75,,,percent of total billed charges,,,,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,800.7,,,fee schedule,,,,,,,,,1191.02,,,percent of total billed charges,,,1387.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY THORACIC S ANDI,3223401,CDM,320,RC,72255,CPT,5573,APC,,,,outpatient,facility,,,1525,1525,402.38,1184.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,1184.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1103,,,fee schedule,,,,,,,,,,,,,,,,,,,,,817.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,402.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
MYELOGRAPHY 2 PLUS REGIONS S ANDI,3223419,CDM,320,RC,72270,CPT,,,,,,inpatient,facility,,,1476,619.92,1254.6,1416.96,,1254.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1284.12,,,percent of total billed charges,,,,,,,,,1328.4,,,percent of total billed charges,,,1416.96,,,percent of total billed charges,,,1402.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1372.68,,,percent of total billed charges,,,1402.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY 2 PLUS REGIONS S ANDI,3223419,CDM,320,RC,72270,CPT,,,,,,outpatient,facility,,,1476,619.92,398.52,1416.96,,1254.6,,,percent of total billed charges,,,398.52,,,percent of total billed charges,,,1015.49,,,percent of total billed charges,,,993.35,,,percent of total billed charges,,,1247.22,,,percent of total billed charges,,,,,,,,,1284.12,,,percent of total billed charges,,,1284.12,,,percent of total billed charges,,,1254.6,,,percent of total billed charges,,,1416.96,,,percent of total billed charges,,,1402.2,,,percent of total billed charges,,,,,,,,,1328.4,,,percent of total billed charges,,,,,,,,,1372.68,,,percent of total billed charges,,,1402.2,,,percent of total billed charges,,,,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,800.7,,,fee schedule,,,,,,,,,1152.76,,,percent of total billed charges,,,1343.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
MYELOGRAPHY 2 PLUS REGIONS S ANDI,3223419,CDM,320,RC,72270,CPT,5573,APC,,,,outpatient,facility,,,1476,1476,402.38,1184.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,1184.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1103,,,fee schedule,,,,,,,,,,,,,,,,,,,,,817.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,402.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR BONES NASAL CMP 3 PLUS VW,3223427,CDM,320,RC,70160,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR BONES NASAL CMP 3 PLUS VW,3223427,CDM,320,RC,70160,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR BONES NASAL CMP 3 PLUS VW,3223427,CDM,320,RC,70160,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TISSUE SOFT NECK,3223435,CDM,320,RC,70360,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TISSUE SOFT NECK,3223435,CDM,320,RC,70360,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TISSUE SOFT NECK,3223435,CDM,320,RC,70360,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FORAMINA OPTIC LT,3223534,CDM,320,RC,70190,CPT,,,,,LT  ,inpatient,facility,,,92,38.64,78.2,88.32,,78.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.04,,,percent of total billed charges,,,,,,,,,82.8,,,percent of total billed charges,,,88.32,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.56,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FORAMINA OPTIC LT,3223534,CDM,320,RC,70190,CPT,,,,,LT  ,outpatient,facility,,,92,38.64,24.84,92.73,,78.2,,,percent of total billed charges,,,24.84,,,percent of total billed charges,,,63.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,77.74,,,percent of total billed charges,,,,,,,,,80.04,,,percent of total billed charges,,,80.04,,,percent of total billed charges,,,78.2,,,percent of total billed charges,,,88.32,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,82.8,,,percent of total billed charges,,,,,,,,,85.56,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,71.85,,,percent of total billed charges,,,83.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FORAMINA OPTIC LT,3223534,CDM,320,RC,70190,CPT,5521,APC,,,LT  ,outpatient,facility,,,92,92,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FORAMINA OPTIC RT,3223542,CDM,320,RC,70190,CPT,,,,,RT  ,inpatient,facility,,,92,38.64,78.2,88.32,,78.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,80.04,,,percent of total billed charges,,,,,,,,,82.8,,,percent of total billed charges,,,88.32,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,85.56,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FORAMINA OPTIC RT,3223542,CDM,320,RC,70190,CPT,,,,,RT  ,outpatient,facility,,,92,38.64,24.84,92.73,,78.2,,,percent of total billed charges,,,24.84,,,percent of total billed charges,,,63.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,77.74,,,percent of total billed charges,,,,,,,,,80.04,,,percent of total billed charges,,,80.04,,,percent of total billed charges,,,78.2,,,percent of total billed charges,,,88.32,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,82.8,,,percent of total billed charges,,,,,,,,,85.56,,,percent of total billed charges,,,87.4,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,71.85,,,percent of total billed charges,,,83.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FORAMINA OPTIC RT,3223542,CDM,320,RC,70190,CPT,5521,APC,,,RT  ,outpatient,facility,,,92,92,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ORBITS CMP 4 PLUS VW,3223567,CDM,320,RC,70200,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ORBITS CMP 4 PLUS VW,3223567,CDM,320,RC,70200,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ORBITS CMP 4 PLUS VW,3223567,CDM,320,RC,70200,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ORTHOPANTOGRAM,3223575,CDM,320,RC,70355,CPT,,,,,,inpatient,facility,,,75,31.5,63.75,72,,63.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ORTHOPANTOGRAM,3223575,CDM,320,RC,70355,CPT,,,,,,outpatient,facility,,,75,31.5,20.25,92.73,,63.75,,,percent of total billed charges,,,20.25,,,percent of total billed charges,,,51.6,,,percent of total billed charges,,,50.47,,,percent of total billed charges,,,63.38,,,percent of total billed charges,,,,,,,,,65.25,,,percent of total billed charges,,,65.25,,,percent of total billed charges,,,63.75,,,percent of total billed charges,,,72,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,67.5,,,percent of total billed charges,,,,,,,,,69.75,,,percent of total billed charges,,,71.25,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,58.58,,,percent of total billed charges,,,68.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ORTHOPANTOGRAM,3223575,CDM,320,RC,70355,CPT,5521,APC,,,,outpatient,facility,,,75,75,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR PELVIS CMP 3 PLUS VW,3223591,CDM,320,RC,72190,CPT,,,,,,inpatient,facility,,,133,55.86,113.05,127.68,,113.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,115.71,,,percent of total billed charges,,,,,,,,,119.7,,,percent of total billed charges,,,127.68,,,percent of total billed charges,,,126.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,123.69,,,percent of total billed charges,,,126.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR PELVIS CMP 3 PLUS VW,3223591,CDM,320,RC,72190,CPT,,,,,,outpatient,facility,,,133,55.86,35.91,127.68,,113.05,,,percent of total billed charges,,,35.91,,,percent of total billed charges,,,91.5,,,percent of total billed charges,,,89.51,,,percent of total billed charges,,,112.38,,,percent of total billed charges,,,,,,,,,115.71,,,percent of total billed charges,,,115.71,,,percent of total billed charges,,,113.05,,,percent of total billed charges,,,127.68,,,percent of total billed charges,,,126.35,,,percent of total billed charges,,,,,,,,,119.7,,,percent of total billed charges,,,,,,,,,123.69,,,percent of total billed charges,,,126.35,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,103.87,,,percent of total billed charges,,,121.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR PELVIS CMP 3 PLUS VW,3223591,CDM,320,RC,72190,CPT,5522,APC,,,,outpatient,facility,,,133,133,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR PELVIS 1 2 VW,3223609,CDM,320,RC,72170,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR PELVIS 1 2 VW,3223609,CDM,320,RC,72170,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR PELVIS 1 2 VW,3223609,CDM,320,RC,72170,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC G TUBE NASO ORO PHYS W FL GD,3223773,CDM,361,RC,43752,CPT,,,,,,inpatient,facility,,,386,162.12,328.1,370.56,,328.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,335.82,,,percent of total billed charges,,,,,,,,,347.4,,,percent of total billed charges,,,370.56,,,percent of total billed charges,,,366.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,358.98,,,percent of total billed charges,,,366.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC G TUBE NASO ORO PHYS W FL GD,3223773,CDM,361,RC,43752,CPT,,,,,,outpatient,facility,,,386,162.12,104.22,3428,,328.1,,,percent of total billed charges,,,104.22,,,percent of total billed charges,,,265.57,,,percent of total billed charges,,,259.78,,,percent of total billed charges,,,326.17,,,percent of total billed charges,,,,,,,,,335.82,,,percent of total billed charges,,,335.82,,,percent of total billed charges,,,328.1,,,percent of total billed charges,,,370.56,,,percent of total billed charges,,,366.7,,,percent of total billed charges,,,,,,,,,347.4,,,percent of total billed charges,,,,,,,,,358.98,,,percent of total billed charges,,,366.7,,,percent of total billed charges,,,,,,,,,,,,,,,406.58,,,fee schedule,,,406.58,,,fee schedule,,,398.45,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,351.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC G TUBE NASO ORO PHYS W FL GD,3223773,CDM,361,RC,43752,CPT,5735,APC,,,,outpatient,facility,,,386,386,205.1,589.54,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,414.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,406.58,,,fee schedule,,,,,,,,,,,,,,,589.54,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",548.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,406.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,406.58,,,fee schedule,,,406.58,,,fee schedule,,,205.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC DEV S OCCLUSIVE,3223781,CDM,361,RC,G0269,HCPCS,,,,,,inpatient,facility,,,693,291.06,589.05,665.28,,589.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,602.91,,,percent of total billed charges,,,,,,,,,623.7,,,percent of total billed charges,,,665.28,,,percent of total billed charges,,,658.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,644.49,,,percent of total billed charges,,,658.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC DEV S OCCLUSIVE,3223781,CDM,361,RC,G0269,HCPCS,,,,,,outpatient,facility,,,693,291.06,187.11,3428,,589.05,,,percent of total billed charges,,,187.11,,,percent of total billed charges,,,476.78,,,percent of total billed charges,,,466.39,,,percent of total billed charges,,,585.59,,,percent of total billed charges,,,,,,,,,602.91,,,percent of total billed charges,,,602.91,,,percent of total billed charges,,,589.05,,,percent of total billed charges,,,665.28,,,percent of total billed charges,,,658.35,,,percent of total billed charges,,,,,,,,,623.7,,,percent of total billed charges,,,,,,,,,644.49,,,percent of total billed charges,,,658.35,,,percent of total billed charges,,,,,,,,,,,,,,,693,,,fee schedule,,,693,,,fee schedule,,,693,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,630.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CATH VEIN PORTAL PERC ANY METHOD,3223815,CDM,361,RC,36481,CPT,,,,,,inpatient,facility,,,6284,2639.28,5341.4,6032.64,,5341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5467.08,,,percent of total billed charges,,,,,,,,,5655.6,,,percent of total billed charges,,,6032.64,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5844.12,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH VEIN PORTAL PERC ANY METHOD,3223815,CDM,361,RC,36481,CPT,,,,,,outpatient,facility,,,6284,2639.28,1696.68,6284,,5341.4,,,percent of total billed charges,,,1696.68,,,percent of total billed charges,,,4323.39,,,percent of total billed charges,,,4229.13,,,percent of total billed charges,,,5309.98,,,percent of total billed charges,,,,,,,,,5467.08,,,percent of total billed charges,,,5467.08,,,percent of total billed charges,,,5341.4,,,percent of total billed charges,,,6032.64,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,5655.6,,,percent of total billed charges,,,,,,,,,5844.12,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,,,,,,,6284,,,fee schedule,,,6284,,,fee schedule,,,6284,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,5718.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PORTOGRAM W EVAL HEMO S ANDI,3223823,CDM,320,RC,75885,CPT,,,,,,inpatient,facility,,,6355,2669.1,5401.75,6100.8,,5401.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5528.85,,,percent of total billed charges,,,,,,,,,5719.5,,,percent of total billed charges,,,6100.8,,,percent of total billed charges,,,6037.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5910.15,,,percent of total billed charges,,,6037.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PORTOGRAM W EVAL HEMO S ANDI,3223823,CDM,320,RC,75885,CPT,,,,,,outpatient,facility,,,6355,2669.1,1715.85,6100.8,,5401.75,,,percent of total billed charges,,,1715.85,,,percent of total billed charges,,,4372.24,,,percent of total billed charges,,,4276.91,,,percent of total billed charges,,,5369.97,,,percent of total billed charges,,,,,,,,,5528.85,,,percent of total billed charges,,,5528.85,,,percent of total billed charges,,,5401.75,,,percent of total billed charges,,,6100.8,,,percent of total billed charges,,,6037.25,,,percent of total billed charges,,,,,,,,,5719.5,,,percent of total billed charges,,,,,,,,,5910.15,,,percent of total billed charges,,,6037.25,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4963.25,,,percent of total billed charges,,,5783.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PORTOGRAM W EVAL HEMO S ANDI,3223823,CDM,320,RC,75885,CPT,5183,APC,,,,outpatient,facility,,,6355,6355,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PORTOGRAM WO EVAL HEMO S ANDI,3223831,CDM,320,RC,75887,CPT,,,,,,inpatient,facility,,,6284,2639.28,5341.4,6032.64,,5341.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5467.08,,,percent of total billed charges,,,,,,,,,5655.6,,,percent of total billed charges,,,6032.64,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5844.12,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PORTOGRAM WO EVAL HEMO S ANDI,3223831,CDM,320,RC,75887,CPT,,,,,,outpatient,facility,,,6284,2639.28,1696.68,6032.64,,5341.4,,,percent of total billed charges,,,1696.68,,,percent of total billed charges,,,4323.39,,,percent of total billed charges,,,4229.13,,,percent of total billed charges,,,5309.98,,,percent of total billed charges,,,,,,,,,5467.08,,,percent of total billed charges,,,5467.08,,,percent of total billed charges,,,5341.4,,,percent of total billed charges,,,6032.64,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,5655.6,,,percent of total billed charges,,,,,,,,,5844.12,,,percent of total billed charges,,,5969.8,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4907.8,,,percent of total billed charges,,,5718.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PORTOGRAM WO EVAL HEMO S ANDI,3223831,CDM,320,RC,75887,CPT,5183,APC,,,,outpatient,facility,,,6284,6284,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PUNCT SHUNT TUBE RESV ASP INJ,3224003,CDM,361,RC,61070,CPT,,,,,,inpatient,facility,,,1349,566.58,1146.65,1295.04,,1146.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1173.63,,,percent of total billed charges,,,,,,,,,1214.1,,,percent of total billed charges,,,1295.04,,,percent of total billed charges,,,1281.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1254.57,,,percent of total billed charges,,,1281.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCT SHUNT TUBE RESV ASP INJ,3224003,CDM,361,RC,61070,CPT,,,,,,outpatient,facility,,,1349,566.58,364.23,3522,,1146.65,,,percent of total billed charges,,,364.23,,,percent of total billed charges,,,928.11,,,percent of total billed charges,,,907.88,,,percent of total billed charges,,,1139.9,,,percent of total billed charges,,,,,,,,,1173.63,,,percent of total billed charges,,,1173.63,,,percent of total billed charges,,,1146.65,,,percent of total billed charges,,,1295.04,,,percent of total billed charges,,,1281.55,,,percent of total billed charges,,,,,,,,,1214.1,,,percent of total billed charges,,,,,,,,,1254.57,,,percent of total billed charges,,,1281.55,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1227.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCT SHUNT TUBE RESV ASP INJ,3224003,CDM,361,RC,61070,CPT,5442,APC,,,,outpatient,facility,,,1349,1349,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM OBSTRUCT MECH CVD PERICATHETER,3224060,CDM,361,RC,36595,CPT,,,,,,inpatient,facility,,,5469,2296.98,4648.65,5250.24,,4648.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4758.03,,,percent of total billed charges,,,,,,,,,4922.1,,,percent of total billed charges,,,5250.24,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5086.17,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM OBSTRUCT MECH CVD PERICATHETER,3224060,CDM,361,RC,36595,CPT,,,,,,outpatient,facility,,,5469,2296.98,1476.63,15487,,4648.65,,,percent of total billed charges,,,1476.63,,,percent of total billed charges,,,3762.67,,,percent of total billed charges,,,3680.64,,,percent of total billed charges,,,4621.31,,,percent of total billed charges,,,,,,,,,4758.03,,,percent of total billed charges,,,4758.03,,,percent of total billed charges,,,4648.65,,,percent of total billed charges,,,5250.24,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,4922.1,,,percent of total billed charges,,,,,,,,,5086.17,,,percent of total billed charges,,,5195.55,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4976.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM OBSTRUCT MECH CVD PERICATHETER,3224060,CDM,361,RC,36595,CPT,5183,APC,,,,outpatient,facility,,,5469,5469,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM OBSTRUCT CVD PERICATHETER S ANDI,3224078,CDM,320,RC,75901,CPT,,,,,,inpatient,facility,,,674,283.08,572.9,647.04,,572.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,586.38,,,percent of total billed charges,,,,,,,,,606.6,,,percent of total billed charges,,,647.04,,,percent of total billed charges,,,640.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,626.82,,,percent of total billed charges,,,640.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM OBSTRUCT CVD PERICATHETER S ANDI,3224078,CDM,320,RC,75901,CPT,,,,,,outpatient,facility,,,674,283.08,181.98,674,,572.9,,,percent of total billed charges,,,181.98,,,percent of total billed charges,,,463.71,,,percent of total billed charges,,,453.6,,,percent of total billed charges,,,569.53,,,percent of total billed charges,,,,,,,,,586.38,,,percent of total billed charges,,,586.38,,,percent of total billed charges,,,572.9,,,percent of total billed charges,,,647.04,,,percent of total billed charges,,,640.3,,,percent of total billed charges,,,,,,,,,606.6,,,percent of total billed charges,,,,,,,,,626.82,,,percent of total billed charges,,,640.3,,,percent of total billed charges,,,,,,,,,,,,,,,674,,,fee schedule,,,674,,,fee schedule,,,674,,,fee schedule,,,,,,,,,526.39,,,percent of total billed charges,,,613.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM CVC TUN WO P P,3224102,CDM,361,RC,36589,CPT,,,,,,inpatient,facility,,,1755,737.1,1491.75,1684.8,,1491.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1526.85,,,percent of total billed charges,,,,,,,,,1579.5,,,percent of total billed charges,,,1684.8,,,percent of total billed charges,,,1667.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1632.15,,,percent of total billed charges,,,1667.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM CVC TUN WO P P,3224102,CDM,361,RC,36589,CPT,,,,,,outpatient,facility,,,1755,737.1,473.85,3522,,1491.75,,,percent of total billed charges,,,473.85,,,percent of total billed charges,,,1207.44,,,percent of total billed charges,,,1181.11,,,percent of total billed charges,,,1482.97,,,percent of total billed charges,,,,,,,,,1526.85,,,percent of total billed charges,,,1526.85,,,percent of total billed charges,,,1491.75,,,percent of total billed charges,,,1684.8,,,percent of total billed charges,,,1667.25,,,percent of total billed charges,,,,,,,,,1579.5,,,percent of total billed charges,,,,,,,,,1632.15,,,percent of total billed charges,,,1667.25,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1597.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM CVC TUN WO P P,3224102,CDM,361,RC,36589,CPT,5181,APC,,,,outpatient,facility,,,1755,1755,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM CVD TUN W P P,3224110,CDM,361,RC,36590,CPT,,,,,,inpatient,facility,,,2421,1016.82,2057.85,2324.16,,2057.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2106.27,,,percent of total billed charges,,,,,,,,,2178.9,,,percent of total billed charges,,,2324.16,,,percent of total billed charges,,,2299.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2251.53,,,percent of total billed charges,,,2299.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM CVD TUN W P P,3224110,CDM,361,RC,36590,CPT,,,,,,outpatient,facility,,,2421,1016.82,653.67,5933,,2057.85,,,percent of total billed charges,,,653.67,,,percent of total billed charges,,,1665.65,,,percent of total billed charges,,,1629.33,,,percent of total billed charges,,,2045.74,,,percent of total billed charges,,,,,,,,,2106.27,,,percent of total billed charges,,,2106.27,,,percent of total billed charges,,,2057.85,,,percent of total billed charges,,,2324.16,,,percent of total billed charges,,,2299.95,,,percent of total billed charges,,,,,,,,,2178.9,,,percent of total billed charges,,,,,,,,,2251.53,,,percent of total billed charges,,,2299.95,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2203.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM CVD TUN W P P,3224110,CDM,361,RC,36590,CPT,5182,APC,,,,outpatient,facility,,,2421,2421,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPR CVD W P P,3224144,CDM,361,RC,36576,CPT,,,,,,inpatient,facility,,,7492,3146.64,6368.2,7192.32,,6368.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6518.04,,,percent of total billed charges,,,,,,,,,6742.8,,,percent of total billed charges,,,7192.32,,,percent of total billed charges,,,7117.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6967.56,,,percent of total billed charges,,,7117.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPR CVD W P P,3224144,CDM,361,RC,36576,CPT,,,,,,outpatient,facility,,,7492,3146.64,1601.58,7192.32,,6368.2,,,percent of total billed charges,,,2022.84,,,percent of total billed charges,,,5154.5,,,percent of total billed charges,,,5042.12,,,percent of total billed charges,,,6330.74,,,percent of total billed charges,,,,,,,,,6518.04,,,percent of total billed charges,,,6518.04,,,percent of total billed charges,,,6368.2,,,percent of total billed charges,,,7192.32,,,percent of total billed charges,,,7117.4,,,percent of total billed charges,,,,,,,,,6742.8,,,percent of total billed charges,,,,,,,,,6967.56,,,percent of total billed charges,,,7117.4,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,6817.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPR CVD W P P,3224144,CDM,361,RC,36576,CPT,5182,APC,,,,outpatient,facility,,,7492,7492,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REPOSITION CVC PREVIOUS W FLUORO,3224169,CDM,361,RC,36597,CPT,,,,,,inpatient,facility,,,2273,954.66,1932.05,2182.08,,1932.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1977.51,,,percent of total billed charges,,,,,,,,,2045.7,,,percent of total billed charges,,,2182.08,,,percent of total billed charges,,,2159.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2113.89,,,percent of total billed charges,,,2159.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REPOSITION CVC PREVIOUS W FLUORO,3224169,CDM,361,RC,36597,CPT,,,,,,outpatient,facility,,,2273,954.66,613.71,3522,,1932.05,,,percent of total billed charges,,,613.71,,,percent of total billed charges,,,1563.82,,,percent of total billed charges,,,1529.73,,,percent of total billed charges,,,1920.68,,,percent of total billed charges,,,,,,,,,1977.51,,,percent of total billed charges,,,1977.51,,,percent of total billed charges,,,1932.05,,,percent of total billed charges,,,2182.08,,,percent of total billed charges,,,2159.35,,,percent of total billed charges,,,,,,,,,2045.7,,,percent of total billed charges,,,,,,,,,2113.89,,,percent of total billed charges,,,2159.35,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2068.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REPOSITION CVC PREVIOUS W FLUORO,3224169,CDM,361,RC,36597,CPT,5182,APC,,,,outpatient,facility,,,2273,2273,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REV TIPS,3224219,CDM,361,RC,37183,CPT,,,,,,inpatient,facility,,,13987,5874.54,11888.95,13427.52,,11888.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12168.69,,,percent of total billed charges,,,,,,,,,12588.3,,,percent of total billed charges,,,13427.52,,,percent of total billed charges,,,13287.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13007.91,,,percent of total billed charges,,,13287.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REV TIPS,3224219,CDM,361,RC,37183,CPT,,,,,,outpatient,facility,,,13987,5874.54,3776.49,29580,,11888.95,,,percent of total billed charges,,,3776.49,,,percent of total billed charges,,,9623.06,,,percent of total billed charges,,,9413.25,,,percent of total billed charges,,,11819.01,,,percent of total billed charges,,,,,,,,,12168.69,,,percent of total billed charges,,,12168.69,,,percent of total billed charges,,,11888.95,,,percent of total billed charges,,,13427.52,,,percent of total billed charges,,,13287.65,,,percent of total billed charges,,,,,,,,,12588.3,,,percent of total billed charges,,,,,,,,,13007.91,,,percent of total billed charges,,,13287.65,,,percent of total billed charges,,,,,,,,,,,,,,,13987,,,fee schedule,,,13987,,,fee schedule,,,13987,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,12728.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REV TIPS,3224219,CDM,361,RC,37183,CPT,5192,APC,,,,outpatient,facility,,,13987,13987,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR RIBS 2 VW LT,3224227,CDM,320,RC,71100,CPT,,,,,LT  ,inpatient,facility,,,101,42.42,85.85,96.96,,85.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.87,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR RIBS 2 VW LT,3224227,CDM,320,RC,71100,CPT,,,,,LT  ,outpatient,facility,,,101,42.42,27.27,96.96,,85.85,,,percent of total billed charges,,,27.27,,,percent of total billed charges,,,69.49,,,percent of total billed charges,,,67.97,,,percent of total billed charges,,,85.34,,,percent of total billed charges,,,,,,,,,87.87,,,percent of total billed charges,,,87.87,,,percent of total billed charges,,,85.85,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,78.88,,,percent of total billed charges,,,91.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR RIBS 2 VW LT,3224227,CDM,320,RC,71100,CPT,5521,APC,,,LT  ,outpatient,facility,,,101,101,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR RIBS 2 VW RT,3224235,CDM,320,RC,71100,CPT,,,,,RT  ,inpatient,facility,,,101,42.42,85.85,96.96,,85.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.87,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR RIBS 2 VW RT,3224235,CDM,320,RC,71100,CPT,,,,,RT  ,outpatient,facility,,,101,42.42,27.27,96.96,,85.85,,,percent of total billed charges,,,27.27,,,percent of total billed charges,,,69.49,,,percent of total billed charges,,,67.97,,,percent of total billed charges,,,85.34,,,percent of total billed charges,,,,,,,,,87.87,,,percent of total billed charges,,,87.87,,,percent of total billed charges,,,85.85,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,78.88,,,percent of total billed charges,,,91.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR RIBS 2 VW RT,3224235,CDM,320,RC,71100,CPT,5521,APC,,,RT  ,outpatient,facility,,,101,101,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR RIBS 3 PLUS VW BI,3224243,CDM,320,RC,71110,CPT,,,,,,inpatient,facility,,,181,76.02,153.85,173.76,,153.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,157.47,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR RIBS 3 PLUS VW BI,3224243,CDM,320,RC,71110,CPT,,,,,,outpatient,facility,,,181,76.02,48.87,173.76,,153.85,,,percent of total billed charges,,,48.87,,,percent of total billed charges,,,124.53,,,percent of total billed charges,,,121.81,,,percent of total billed charges,,,152.94,,,percent of total billed charges,,,,,,,,,157.47,,,percent of total billed charges,,,157.47,,,percent of total billed charges,,,153.85,,,percent of total billed charges,,,173.76,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,162.9,,,percent of total billed charges,,,,,,,,,168.33,,,percent of total billed charges,,,171.95,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,141.36,,,percent of total billed charges,,,164.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR RIBS 3 PLUS VW BI,3224243,CDM,320,RC,71110,CPT,5522,APC,,,,outpatient,facility,,,181,181,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR RIBS W CXR 4 PLUS VW BI,3224276,CDM,320,RC,71111,CPT,,,,,,inpatient,facility,,,214,89.88,181.9,205.44,,181.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,186.18,,,percent of total billed charges,,,,,,,,,192.6,,,percent of total billed charges,,,205.44,,,percent of total billed charges,,,203.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,199.02,,,percent of total billed charges,,,203.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR RIBS W CXR 4 PLUS VW BI,3224276,CDM,320,RC,71111,CPT,,,,,,outpatient,facility,,,214,89.88,57.78,205.44,,181.9,,,percent of total billed charges,,,57.78,,,percent of total billed charges,,,147.23,,,percent of total billed charges,,,144.02,,,percent of total billed charges,,,180.83,,,percent of total billed charges,,,,,,,,,186.18,,,percent of total billed charges,,,186.18,,,percent of total billed charges,,,181.9,,,percent of total billed charges,,,205.44,,,percent of total billed charges,,,203.3,,,percent of total billed charges,,,,,,,,,192.6,,,percent of total billed charges,,,,,,,,,199.02,,,percent of total billed charges,,,203.3,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,167.13,,,percent of total billed charges,,,194.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR RIBS W CXR 4 PLUS VW BI,3224276,CDM,320,RC,71111,CPT,5522,APC,,,,outpatient,facility,,,214,214,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC CICVC NONTUN WO P P,3224292,CDM,361,RC,36580,CPT,,,,,,inpatient,facility,,,1751,735.42,1488.35,1680.96,,1488.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1523.37,,,percent of total billed charges,,,,,,,,,1575.9,,,percent of total billed charges,,,1680.96,,,percent of total billed charges,,,1663.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1628.43,,,percent of total billed charges,,,1663.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC CICVC NONTUN WO P P,3224292,CDM,361,RC,36580,CPT,,,,,,outpatient,facility,,,1751,735.42,472.77,3522,,1488.35,,,percent of total billed charges,,,472.77,,,percent of total billed charges,,,1204.69,,,percent of total billed charges,,,1178.42,,,percent of total billed charges,,,1479.6,,,percent of total billed charges,,,,,,,,,1523.37,,,percent of total billed charges,,,1523.37,,,percent of total billed charges,,,1488.35,,,percent of total billed charges,,,1680.96,,,percent of total billed charges,,,1663.45,,,percent of total billed charges,,,,,,,,,1575.9,,,percent of total billed charges,,,,,,,,,1628.43,,,percent of total billed charges,,,1663.45,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1593.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC CICVC NONTUN WO P P,3224292,CDM,361,RC,36580,CPT,5182,APC,,,,outpatient,facility,,,1751,1751,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC PICVD W PORT,3224318,CDM,361,RC,36585,CPT,,,,,,inpatient,facility,,,7269,3052.98,6178.65,6978.24,,6178.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6324.03,,,percent of total billed charges,,,,,,,,,6542.1,,,percent of total billed charges,,,6978.24,,,percent of total billed charges,,,6905.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6760.17,,,percent of total billed charges,,,6905.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC PICVD W PORT,3224318,CDM,361,RC,36585,CPT,,,,,,outpatient,facility,,,7269,3052.98,1962.63,15487,,6178.65,,,percent of total billed charges,,,1962.63,,,percent of total billed charges,,,5001.07,,,percent of total billed charges,,,4892.04,,,percent of total billed charges,,,6142.3,,,percent of total billed charges,,,,,,,,,6324.03,,,percent of total billed charges,,,6324.03,,,percent of total billed charges,,,6178.65,,,percent of total billed charges,,,6978.24,,,percent of total billed charges,,,6905.55,,,percent of total billed charges,,,,,,,,,6542.1,,,percent of total billed charges,,,,,,,,,6760.17,,,percent of total billed charges,,,6905.55,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6614.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC PICVD W PORT,3224318,CDM,361,RC,36585,CPT,5183,APC,,,,outpatient,facility,,,7269,7269,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC CICVC TUN WO P P,3224326,CDM,361,RC,36581,CPT,,,,,,inpatient,facility,,,4735,1988.7,4024.75,4545.6,,4024.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4119.45,,,percent of total billed charges,,,,,,,,,4261.5,,,percent of total billed charges,,,4545.6,,,percent of total billed charges,,,4498.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4403.55,,,percent of total billed charges,,,4498.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC CICVC TUN WO P P,3224326,CDM,361,RC,36581,CPT,,,,,,outpatient,facility,,,4735,1988.7,1278.45,15487,,4024.75,,,percent of total billed charges,,,1278.45,,,percent of total billed charges,,,3257.68,,,percent of total billed charges,,,3186.65,,,percent of total billed charges,,,4001.07,,,percent of total billed charges,,,,,,,,,4119.45,,,percent of total billed charges,,,4119.45,,,percent of total billed charges,,,4024.75,,,percent of total billed charges,,,4545.6,,,percent of total billed charges,,,4498.25,,,percent of total billed charges,,,,,,,,,4261.5,,,percent of total billed charges,,,,,,,,,4403.55,,,percent of total billed charges,,,4498.25,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4308.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC CICVC TUN WO P P,3224326,CDM,361,RC,36581,CPT,5183,APC,,,,outpatient,facility,,,4735,4735,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC CICVC TUN W PORT,3224334,CDM,361,RC,36582,CPT,,,,,,inpatient,facility,,,7433,3121.86,6318.05,7135.68,,6318.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6466.71,,,percent of total billed charges,,,,,,,,,6689.7,,,percent of total billed charges,,,7135.68,,,percent of total billed charges,,,7061.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6912.69,,,percent of total billed charges,,,7061.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC CICVC TUN W PORT,3224334,CDM,361,RC,36582,CPT,,,,,,outpatient,facility,,,7433,3121.86,2006.91,15487,,6318.05,,,percent of total billed charges,,,2006.91,,,percent of total billed charges,,,5113.9,,,percent of total billed charges,,,5002.41,,,percent of total billed charges,,,6280.89,,,percent of total billed charges,,,,,,,,,6466.71,,,percent of total billed charges,,,6466.71,,,percent of total billed charges,,,6318.05,,,percent of total billed charges,,,7135.68,,,percent of total billed charges,,,7061.35,,,percent of total billed charges,,,,,,,,,6689.7,,,percent of total billed charges,,,,,,,,,6912.69,,,percent of total billed charges,,,7061.35,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6764.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC CICVC TUN W PORT,3224334,CDM,361,RC,36582,CPT,5183,APC,,,,outpatient,facility,,,7433,7433,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC CICVC TUN W PUMP,3224342,CDM,361,RC,36583,CPT,,,,,,inpatient,facility,,,8333,3499.86,7083.05,7999.68,,7083.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7249.71,,,percent of total billed charges,,,,,,,,,7499.7,,,percent of total billed charges,,,7999.68,,,percent of total billed charges,,,7916.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7749.69,,,percent of total billed charges,,,7916.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC CICVC TUN W PUMP,3224342,CDM,361,RC,36583,CPT,,,,,,outpatient,facility,,,8333,3499.86,2249.91,28046,,7083.05,,,percent of total billed charges,,,2249.91,,,percent of total billed charges,,,5733.1,,,percent of total billed charges,,,5608.11,,,percent of total billed charges,,,7041.39,,,percent of total billed charges,,,,,,,,,7249.71,,,percent of total billed charges,,,7249.71,,,percent of total billed charges,,,7083.05,,,percent of total billed charges,,,7999.68,,,percent of total billed charges,,,7916.35,,,percent of total billed charges,,,,,,,,,7499.7,,,percent of total billed charges,,,,,,,,,7749.69,,,percent of total billed charges,,,7916.35,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,7583.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC CICVC TUN W PUMP,3224342,CDM,361,RC,36583,CPT,5184,APC,,,,outpatient,facility,,,8333,8333,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SACRUM ANDCOCCYX 2 PLUS VW,3224359,CDM,320,RC,72220,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SACRUM ANDCOCCYX 2 PLUS VW,3224359,CDM,320,RC,72220,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SACRUM ANDCOCCYX 2 PLUS VW,3224359,CDM,320,RC,72220,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SCAPULA CMP LT,3224383,CDM,320,RC,73010,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SCAPULA CMP LT,3224383,CDM,320,RC,73010,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SCAPULA CMP LT,3224383,CDM,320,RC,73010,CPT,5522,APC,,,LT  ,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SCAPULA CMP RT,3224391,CDM,320,RC,73010,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SCAPULA CMP RT,3224391,CDM,320,RC,73010,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SCAPULA CMP RT,3224391,CDM,320,RC,73010,CPT,5522,APC,,,RT  ,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART PULM BI,3224409,CDM,361,RC,36014,CPT,,,,,50,inpatient,facility,,,586,246.12,498.1,562.56,,498.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,509.82,,,percent of total billed charges,,,,,,,,,527.4,,,percent of total billed charges,,,562.56,,,percent of total billed charges,,,556.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,544.98,,,percent of total billed charges,,,556.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM BI,3224409,CDM,361,RC,36014,CPT,,,,,50,outpatient,facility,,,586,246.12,158.22,3428,,498.1,,,percent of total billed charges,,,158.22,,,percent of total billed charges,,,403.17,,,percent of total billed charges,,,394.38,,,percent of total billed charges,,,495.17,,,percent of total billed charges,,,,,,,,,509.82,,,percent of total billed charges,,,509.82,,,percent of total billed charges,,,498.1,,,percent of total billed charges,,,562.56,,,percent of total billed charges,,,556.7,,,percent of total billed charges,,,,,,,,,527.4,,,percent of total billed charges,,,,,,,,,544.98,,,percent of total billed charges,,,556.7,,,percent of total billed charges,,,,,,,,,,,,,,,586,,,fee schedule,,,586,,,fee schedule,,,586,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,533.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM LT,3224417,CDM,361,RC,36014,CPT,,,,,LT  ,inpatient,facility,,,391,164.22,332.35,375.36,,332.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.17,,,percent of total billed charges,,,,,,,,,351.9,,,percent of total billed charges,,,375.36,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363.63,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM LT,3224417,CDM,361,RC,36014,CPT,,,,,LT  ,outpatient,facility,,,391,164.22,105.57,3428,,332.35,,,percent of total billed charges,,,105.57,,,percent of total billed charges,,,269.01,,,percent of total billed charges,,,263.14,,,percent of total billed charges,,,330.39,,,percent of total billed charges,,,,,,,,,340.17,,,percent of total billed charges,,,340.17,,,percent of total billed charges,,,332.35,,,percent of total billed charges,,,375.36,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,351.9,,,percent of total billed charges,,,,,,,,,363.63,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,,,,,,,391,,,fee schedule,,,391,,,fee schedule,,,391,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,355.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM RT,3224425,CDM,361,RC,36014,CPT,,,,,RT  ,inpatient,facility,,,391,164.22,332.35,375.36,,332.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,340.17,,,percent of total billed charges,,,,,,,,,351.9,,,percent of total billed charges,,,375.36,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,363.63,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM RT,3224425,CDM,361,RC,36014,CPT,,,,,RT  ,outpatient,facility,,,391,164.22,105.57,3428,,332.35,,,percent of total billed charges,,,105.57,,,percent of total billed charges,,,269.01,,,percent of total billed charges,,,263.14,,,percent of total billed charges,,,330.39,,,percent of total billed charges,,,,,,,,,340.17,,,percent of total billed charges,,,340.17,,,percent of total billed charges,,,332.35,,,percent of total billed charges,,,375.36,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,351.9,,,percent of total billed charges,,,,,,,,,363.63,,,percent of total billed charges,,,371.45,,,percent of total billed charges,,,,,,,,,,,,,,,391,,,fee schedule,,,391,,,fee schedule,,,391,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,355.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT 1ST ORD,3224433,CDM,361,RC,36245,CPT,,,,,,inpatient,facility,,,2024,850.08,1720.4,1943.04,,1720.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1760.88,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,1943.04,,,percent of total billed charges,,,1922.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1882.32,,,percent of total billed charges,,,1922.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT 1ST ORD,3224433,CDM,361,RC,36245,CPT,,,,,,outpatient,facility,,,2024,850.08,546.48,3428,,1720.4,,,percent of total billed charges,,,546.48,,,percent of total billed charges,,,1392.51,,,percent of total billed charges,,,1362.15,,,percent of total billed charges,,,1710.28,,,percent of total billed charges,,,,,,,,,1760.88,,,percent of total billed charges,,,1760.88,,,percent of total billed charges,,,1720.4,,,percent of total billed charges,,,1943.04,,,percent of total billed charges,,,1922.8,,,percent of total billed charges,,,,,,,,,1821.6,,,percent of total billed charges,,,,,,,,,1882.32,,,percent of total billed charges,,,1922.8,,,percent of total billed charges,,,,,,,,,,,,,,,2024,,,fee schedule,,,2024,,,fee schedule,,,2024,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1841.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT 2ND ORD,3224441,CDM,361,RC,36246,CPT,,,,,,inpatient,facility,,,2780,1167.6,2363,2668.8,,2363,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2418.6,,,percent of total billed charges,,,,,,,,,2502,,,percent of total billed charges,,,2668.8,,,percent of total billed charges,,,2641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2585.4,,,percent of total billed charges,,,2641,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT 2ND ORD,3224441,CDM,361,RC,36246,CPT,,,,,,outpatient,facility,,,2780,1167.6,750.6,3428,,2363,,,percent of total billed charges,,,750.6,,,percent of total billed charges,,,1912.64,,,percent of total billed charges,,,1870.94,,,percent of total billed charges,,,2349.1,,,percent of total billed charges,,,,,,,,,2418.6,,,percent of total billed charges,,,2418.6,,,percent of total billed charges,,,2363,,,percent of total billed charges,,,2668.8,,,percent of total billed charges,,,2641,,,percent of total billed charges,,,,,,,,,2502,,,percent of total billed charges,,,,,,,,,2585.4,,,percent of total billed charges,,,2641,,,percent of total billed charges,,,,,,,,,,,,,,,2780,,,fee schedule,,,2780,,,fee schedule,,,2780,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2529.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT 3RD ORD,3224458,CDM,361,RC,36247,CPT,,,,,,inpatient,facility,,,3310,1390.2,2813.5,3177.6,,2813.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2879.7,,,percent of total billed charges,,,,,,,,,2979,,,percent of total billed charges,,,3177.6,,,percent of total billed charges,,,3144.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3078.3,,,percent of total billed charges,,,3144.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT 3RD ORD,3224458,CDM,361,RC,36247,CPT,,,,,,outpatient,facility,,,3310,1390.2,893.7,3428,,2813.5,,,percent of total billed charges,,,893.7,,,percent of total billed charges,,,2277.28,,,percent of total billed charges,,,2227.63,,,percent of total billed charges,,,2796.95,,,percent of total billed charges,,,,,,,,,2879.7,,,percent of total billed charges,,,2879.7,,,percent of total billed charges,,,2813.5,,,percent of total billed charges,,,3177.6,,,percent of total billed charges,,,3144.5,,,percent of total billed charges,,,,,,,,,2979,,,percent of total billed charges,,,,,,,,,3078.3,,,percent of total billed charges,,,3144.5,,,percent of total billed charges,,,,,,,,,,,,,,,3310,,,fee schedule,,,3310,,,fee schedule,,,3310,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3012.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT ADDL,3224466,CDM,361,RC,36248,CPT,,,,,,inpatient,facility,,,1953,820.26,1660.05,1874.88,,1660.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1699.11,,,percent of total billed charges,,,,,,,,,1757.7,,,percent of total billed charges,,,1874.88,,,percent of total billed charges,,,1855.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1816.29,,,percent of total billed charges,,,1855.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART ABD EXT ADDL,3224466,CDM,361,RC,36248,CPT,,,,,,outpatient,facility,,,1953,820.26,527.31,3428,,1660.05,,,percent of total billed charges,,,527.31,,,percent of total billed charges,,,1343.66,,,percent of total billed charges,,,1314.37,,,percent of total billed charges,,,1650.28,,,percent of total billed charges,,,,,,,,,1699.11,,,percent of total billed charges,,,1699.11,,,percent of total billed charges,,,1660.05,,,percent of total billed charges,,,1874.88,,,percent of total billed charges,,,1855.35,,,percent of total billed charges,,,,,,,,,1757.7,,,percent of total billed charges,,,,,,,,,1816.29,,,percent of total billed charges,,,1855.35,,,percent of total billed charges,,,,,,,,,,,,,,,1953,,,fee schedule,,,1953,,,fee schedule,,,1953,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1777.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM 2ND ORD LT,3224474,CDM,361,RC,36015,CPT,,,,,LT  ,inpatient,facility,,,445,186.9,378.25,427.2,,378.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.15,,,percent of total billed charges,,,,,,,,,400.5,,,percent of total billed charges,,,427.2,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,413.85,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM 2ND ORD LT,3224474,CDM,361,RC,36015,CPT,,,,,LT  ,outpatient,facility,,,445,186.9,120.15,3428,,378.25,,,percent of total billed charges,,,120.15,,,percent of total billed charges,,,306.16,,,percent of total billed charges,,,299.48,,,percent of total billed charges,,,376.02,,,percent of total billed charges,,,,,,,,,387.15,,,percent of total billed charges,,,387.15,,,percent of total billed charges,,,378.25,,,percent of total billed charges,,,427.2,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,400.5,,,percent of total billed charges,,,,,,,,,413.85,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,,,,,,,445,,,fee schedule,,,445,,,fee schedule,,,445,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,404.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM 2ND ORD RT,3224482,CDM,361,RC,36015,CPT,,,,,RT  ,inpatient,facility,,,445,186.9,378.25,427.2,,378.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,387.15,,,percent of total billed charges,,,,,,,,,400.5,,,percent of total billed charges,,,427.2,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,413.85,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART PULM 2ND ORD RT,3224482,CDM,361,RC,36015,CPT,,,,,RT  ,outpatient,facility,,,445,186.9,120.15,3428,,378.25,,,percent of total billed charges,,,120.15,,,percent of total billed charges,,,306.16,,,percent of total billed charges,,,299.48,,,percent of total billed charges,,,376.02,,,percent of total billed charges,,,,,,,,,387.15,,,percent of total billed charges,,,387.15,,,percent of total billed charges,,,378.25,,,percent of total billed charges,,,427.2,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,400.5,,,percent of total billed charges,,,,,,,,,413.85,,,percent of total billed charges,,,422.75,,,percent of total billed charges,,,,,,,,,,,,,,,445,,,fee schedule,,,445,,,fee schedule,,,445,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,404.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH 1ST ORD,3224490,CDM,361,RC,36215,CPT,,,,,,inpatient,facility,,,1490,625.8,1266.5,1430.4,,1266.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1296.3,,,percent of total billed charges,,,,,,,,,1341,,,percent of total billed charges,,,1430.4,,,percent of total billed charges,,,1415.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1385.7,,,percent of total billed charges,,,1415.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH 1ST ORD,3224490,CDM,361,RC,36215,CPT,,,,,,outpatient,facility,,,1490,625.8,402.3,3428,,1266.5,,,percent of total billed charges,,,402.3,,,percent of total billed charges,,,1025.12,,,percent of total billed charges,,,1002.77,,,percent of total billed charges,,,1259.05,,,percent of total billed charges,,,,,,,,,1296.3,,,percent of total billed charges,,,1296.3,,,percent of total billed charges,,,1266.5,,,percent of total billed charges,,,1430.4,,,percent of total billed charges,,,1415.5,,,percent of total billed charges,,,,,,,,,1341,,,percent of total billed charges,,,,,,,,,1385.7,,,percent of total billed charges,,,1415.5,,,percent of total billed charges,,,,,,,,,,,,,,,1490,,,fee schedule,,,1490,,,fee schedule,,,1490,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1355.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH 2ND ORD,3224508,CDM,361,RC,36216,CPT,,,,,,inpatient,facility,,,1885,791.7,1602.25,1809.6,,1602.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1639.95,,,percent of total billed charges,,,,,,,,,1696.5,,,percent of total billed charges,,,1809.6,,,percent of total billed charges,,,1790.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1753.05,,,percent of total billed charges,,,1790.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH 2ND ORD,3224508,CDM,361,RC,36216,CPT,,,,,,outpatient,facility,,,1885,791.7,508.95,3428,,1602.25,,,percent of total billed charges,,,508.95,,,percent of total billed charges,,,1296.88,,,percent of total billed charges,,,1268.6,,,percent of total billed charges,,,1592.83,,,percent of total billed charges,,,,,,,,,1639.95,,,percent of total billed charges,,,1639.95,,,percent of total billed charges,,,1602.25,,,percent of total billed charges,,,1809.6,,,percent of total billed charges,,,1790.75,,,percent of total billed charges,,,,,,,,,1696.5,,,percent of total billed charges,,,,,,,,,1753.05,,,percent of total billed charges,,,1790.75,,,percent of total billed charges,,,,,,,,,,,,,,,1885,,,fee schedule,,,1885,,,fee schedule,,,1885,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1715.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH 3RD ORD,3224516,CDM,361,RC,36217,CPT,,,,,,inpatient,facility,,,2271,953.82,1930.35,2180.16,,1930.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1975.77,,,percent of total billed charges,,,,,,,,,2043.9,,,percent of total billed charges,,,2180.16,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2112.03,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH 3RD ORD,3224516,CDM,361,RC,36217,CPT,,,,,,outpatient,facility,,,2271,953.82,613.17,3428,,1930.35,,,percent of total billed charges,,,613.17,,,percent of total billed charges,,,1562.45,,,percent of total billed charges,,,1528.38,,,percent of total billed charges,,,1918.99,,,percent of total billed charges,,,,,,,,,1975.77,,,percent of total billed charges,,,1975.77,,,percent of total billed charges,,,1930.35,,,percent of total billed charges,,,2180.16,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,2043.9,,,percent of total billed charges,,,,,,,,,2112.03,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,,,,,,,2271,,,fee schedule,,,2271,,,fee schedule,,,2271,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2066.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH ADDL,3224524,CDM,361,RC,36218,CPT,,,,,,inpatient,facility,,,364,152.88,309.4,349.44,,309.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,316.68,,,percent of total billed charges,,,,,,,,,327.6,,,percent of total billed charges,,,349.44,,,percent of total billed charges,,,345.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,338.52,,,percent of total billed charges,,,345.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART THOR BRACH ADDL,3224524,CDM,361,RC,36218,CPT,,,,,,outpatient,facility,,,364,152.88,98.28,3428,,309.4,,,percent of total billed charges,,,98.28,,,percent of total billed charges,,,250.43,,,percent of total billed charges,,,244.97,,,percent of total billed charges,,,307.58,,,percent of total billed charges,,,,,,,,,316.68,,,percent of total billed charges,,,316.68,,,percent of total billed charges,,,309.4,,,percent of total billed charges,,,349.44,,,percent of total billed charges,,,345.8,,,percent of total billed charges,,,,,,,,,327.6,,,percent of total billed charges,,,,,,,,,338.52,,,percent of total billed charges,,,345.8,,,percent of total billed charges,,,,,,,,,,,,,,,364,,,fee schedule,,,364,,,fee schedule,,,364,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,331.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL VENOUS BRANCH 1ST ORD,3224532,CDM,361,RC,36011,CPT,,,,,,inpatient,facility,,,1806,758.52,1535.1,1733.76,,1535.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1571.22,,,percent of total billed charges,,,,,,,,,1625.4,,,percent of total billed charges,,,1733.76,,,percent of total billed charges,,,1715.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1679.58,,,percent of total billed charges,,,1715.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL VENOUS BRANCH 1ST ORD,3224532,CDM,361,RC,36011,CPT,,,,,,outpatient,facility,,,1806,758.52,487.62,3428,,1535.1,,,percent of total billed charges,,,487.62,,,percent of total billed charges,,,1242.53,,,percent of total billed charges,,,1215.44,,,percent of total billed charges,,,1526.07,,,percent of total billed charges,,,,,,,,,1571.22,,,percent of total billed charges,,,1571.22,,,percent of total billed charges,,,1535.1,,,percent of total billed charges,,,1733.76,,,percent of total billed charges,,,1715.7,,,percent of total billed charges,,,,,,,,,1625.4,,,percent of total billed charges,,,,,,,,,1679.58,,,percent of total billed charges,,,1715.7,,,percent of total billed charges,,,,,,,,,,,,,,,1806,,,fee schedule,,,1806,,,fee schedule,,,1806,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1643.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL VENOUS BRANCH 2 PLUS ORD,3224540,CDM,361,RC,36012,CPT,,,,,,inpatient,facility,,,2007,842.94,1705.95,1926.72,,1705.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1746.09,,,percent of total billed charges,,,,,,,,,1806.3,,,percent of total billed charges,,,1926.72,,,percent of total billed charges,,,1906.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1866.51,,,percent of total billed charges,,,1906.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL VENOUS BRANCH 2 PLUS ORD,3224540,CDM,361,RC,36012,CPT,,,,,,outpatient,facility,,,2007,842.94,541.89,3428,,1705.95,,,percent of total billed charges,,,541.89,,,percent of total billed charges,,,1380.82,,,percent of total billed charges,,,1350.71,,,percent of total billed charges,,,1695.91,,,percent of total billed charges,,,,,,,,,1746.09,,,percent of total billed charges,,,1746.09,,,percent of total billed charges,,,1705.95,,,percent of total billed charges,,,1926.72,,,percent of total billed charges,,,1906.65,,,percent of total billed charges,,,,,,,,,1806.3,,,percent of total billed charges,,,,,,,,,1866.51,,,percent of total billed charges,,,1906.65,,,percent of total billed charges,,,,,,,,,,,,,,,2007,,,fee schedule,,,2007,,,fee schedule,,,2007,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1826.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SHOULDER CMP 2 PLUS VW LT,3224565,CDM,320,RC,73030,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SHOULDER CMP 2 PLUS VW LT,3224565,CDM,320,RC,73030,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SHOULDER CMP 2 PLUS VW LT,3224565,CDM,320,RC,73030,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SHOULDER CMP 2 PLUS VW RT,3224573,CDM,320,RC,73030,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SHOULDER CMP 2 PLUS VW RT,3224573,CDM,320,RC,73030,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SHOULDER CMP 2 PLUS VW RT,3224573,CDM,320,RC,73030,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SHOULDER 1 VW LT,3224599,CDM,320,RC,73020,CPT,,,,,LT  ,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SHOULDER 1 VW LT,3224599,CDM,320,RC,73020,CPT,,,,,LT  ,outpatient,facility,,,88,36.96,23.76,92.73,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,,,,,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SHOULDER 1 VW LT,3224599,CDM,320,RC,73020,CPT,5521,APC,,,LT  ,outpatient,facility,,,88,88,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SHOULDER 1 VW RT,3224607,CDM,320,RC,73020,CPT,,,,,RT  ,inpatient,facility,,,88,36.96,74.8,84.48,,74.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.56,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SHOULDER 1 VW RT,3224607,CDM,320,RC,73020,CPT,,,,,RT  ,outpatient,facility,,,88,36.96,23.76,92.73,,74.8,,,percent of total billed charges,,,23.76,,,percent of total billed charges,,,60.54,,,percent of total billed charges,,,59.22,,,percent of total billed charges,,,74.36,,,percent of total billed charges,,,,,,,,,76.56,,,percent of total billed charges,,,76.56,,,percent of total billed charges,,,74.8,,,percent of total billed charges,,,84.48,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,79.2,,,percent of total billed charges,,,,,,,,,81.84,,,percent of total billed charges,,,83.6,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,68.73,,,percent of total billed charges,,,80.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SHOULDER 1 VW RT,3224607,CDM,320,RC,73020,CPT,5521,APC,,,RT  ,outpatient,facility,,,88,88,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
SHUNTOGRAM NONVASCULAR S ANDI,3224623,CDM,320,RC,75809,CPT,,,,,,inpatient,facility,,,680,285.6,578,652.8,,578,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,591.6,,,percent of total billed charges,,,,,,,,,612,,,percent of total billed charges,,,652.8,,,percent of total billed charges,,,646,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,632.4,,,percent of total billed charges,,,646,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SHUNTOGRAM NONVASCULAR S ANDI,3224623,CDM,320,RC,75809,CPT,,,,,,outpatient,facility,,,680,285.6,109.95,652.8,,578,,,percent of total billed charges,,,183.6,,,percent of total billed charges,,,467.84,,,percent of total billed charges,,,457.64,,,percent of total billed charges,,,574.6,,,percent of total billed charges,,,,,,,,,591.6,,,percent of total billed charges,,,591.6,,,percent of total billed charges,,,578,,,percent of total billed charges,,,652.8,,,percent of total billed charges,,,646,,,percent of total billed charges,,,,,,,,,612,,,percent of total billed charges,,,,,,,,,632.4,,,percent of total billed charges,,,646,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,531.08,,,percent of total billed charges,,,618.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SHUNTOGRAM NONVASCULAR S ANDI,3224623,CDM,320,RC,75809,CPT,5522,APC,,,,outpatient,facility,,,680,680,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR JTS SACROILIAC 1 2 VW,3224631,CDM,320,RC,72200,CPT,,,,,,inpatient,facility,,,112,47.04,95.2,107.52,,95.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,97.44,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR JTS SACROILIAC 1 2 VW,3224631,CDM,320,RC,72200,CPT,,,,,,outpatient,facility,,,112,47.04,30.24,112.19,,95.2,,,percent of total billed charges,,,30.24,,,percent of total billed charges,,,77.06,,,percent of total billed charges,,,75.38,,,percent of total billed charges,,,94.64,,,percent of total billed charges,,,,,,,,,97.44,,,percent of total billed charges,,,97.44,,,percent of total billed charges,,,95.2,,,percent of total billed charges,,,107.52,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,100.8,,,percent of total billed charges,,,,,,,,,104.16,,,percent of total billed charges,,,106.4,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,87.47,,,percent of total billed charges,,,101.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR JTS SACROILIAC 1 2 VW,3224631,CDM,320,RC,72200,CPT,5522,APC,,,,outpatient,facility,,,112,112,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR JTS SACROILIAC 3 PLUS VW,3224649,CDM,320,RC,72202,CPT,,,,,,inpatient,facility,,,127,53.34,107.95,121.92,,107.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,110.49,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR JTS SACROILIAC 3 PLUS VW,3224649,CDM,320,RC,72202,CPT,,,,,,outpatient,facility,,,127,53.34,34.29,121.92,,107.95,,,percent of total billed charges,,,34.29,,,percent of total billed charges,,,87.38,,,percent of total billed charges,,,85.47,,,percent of total billed charges,,,107.31,,,percent of total billed charges,,,,,,,,,110.49,,,percent of total billed charges,,,110.49,,,percent of total billed charges,,,107.95,,,percent of total billed charges,,,121.92,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,114.3,,,percent of total billed charges,,,,,,,,,118.11,,,percent of total billed charges,,,120.65,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,99.19,,,percent of total billed charges,,,115.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR JTS SACROILIAC 3 PLUS VW,3224649,CDM,320,RC,72202,CPT,5522,APC,,,,outpatient,facility,,,127,127,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SINUSES PARANASAL 0 2 VW,3224672,CDM,320,RC,70210,CPT,,,,,,inpatient,facility,,,90,37.8,76.5,86.4,,76.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,78.3,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SINUSES PARANASAL 0 2 VW,3224672,CDM,320,RC,70210,CPT,,,,,,outpatient,facility,,,90,37.8,24.3,92.73,,76.5,,,percent of total billed charges,,,24.3,,,percent of total billed charges,,,61.92,,,percent of total billed charges,,,60.57,,,percent of total billed charges,,,76.05,,,percent of total billed charges,,,,,,,,,78.3,,,percent of total billed charges,,,78.3,,,percent of total billed charges,,,76.5,,,percent of total billed charges,,,86.4,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,81,,,percent of total billed charges,,,,,,,,,83.7,,,percent of total billed charges,,,85.5,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,70.29,,,percent of total billed charges,,,81.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SINUSES PARANASAL 0 2 VW,3224672,CDM,320,RC,70210,CPT,5521,APC,,,,outpatient,facility,,,90,90,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SINUSES PARANASAL CMP 3 PLUS VW,3224680,CDM,320,RC,70220,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SINUSES PARANASAL CMP 3 PLUS VW,3224680,CDM,320,RC,70220,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SINUSES PARANASAL CMP 3 PLUS VW,3224680,CDM,320,RC,70220,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SKULL 0 3 VW,3224698,CDM,320,RC,70250,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SKULL 0 3 VW,3224698,CDM,320,RC,70250,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SKULL 0 3 VW,3224698,CDM,320,RC,70250,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SKULL CMP 4 PLUS VW,3224706,CDM,320,RC,70260,CPT,,,,,,inpatient,facility,,,139,58.38,118.15,133.44,,118.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,120.93,,,percent of total billed charges,,,,,,,,,125.1,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SKULL CMP 4 PLUS VW,3224706,CDM,320,RC,70260,CPT,,,,,,outpatient,facility,,,139,58.38,37.53,133.44,,118.15,,,percent of total billed charges,,,37.53,,,percent of total billed charges,,,95.63,,,percent of total billed charges,,,93.55,,,percent of total billed charges,,,117.45,,,percent of total billed charges,,,,,,,,,120.93,,,percent of total billed charges,,,120.93,,,percent of total billed charges,,,118.15,,,percent of total billed charges,,,133.44,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,125.1,,,percent of total billed charges,,,,,,,,,129.27,,,percent of total billed charges,,,132.05,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,108.56,,,percent of total billed charges,,,126.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SKULL CMP 4 PLUS VW,3224706,CDM,320,RC,70260,CPT,5522,APC,,,,outpatient,facility,,,139,139,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE 1 VW,3224748,CDM,320,RC,72020,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE 1 VW,3224748,CDM,320,RC,72020,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE 1 VW,3224748,CDM,320,RC,72020,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE CERVICAL 2 3 VW,3224771,CDM,320,RC,72040,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE CERVICAL 2 3 VW,3224771,CDM,320,RC,72040,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE CERVICAL 2 3 VW,3224771,CDM,320,RC,72040,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE LS 4 PLUS VW,3224797,CDM,320,RC,72110,CPT,,,,,,inpatient,facility,,,156,65.52,132.6,149.76,,132.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.72,,,percent of total billed charges,,,,,,,,,140.4,,,percent of total billed charges,,,149.76,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.08,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE LS 4 PLUS VW,3224797,CDM,320,RC,72110,CPT,,,,,,outpatient,facility,,,156,65.52,42.12,149.76,,132.6,,,percent of total billed charges,,,42.12,,,percent of total billed charges,,,107.33,,,percent of total billed charges,,,104.99,,,percent of total billed charges,,,131.82,,,percent of total billed charges,,,,,,,,,135.72,,,percent of total billed charges,,,135.72,,,percent of total billed charges,,,132.6,,,percent of total billed charges,,,149.76,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,140.4,,,percent of total billed charges,,,,,,,,,145.08,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,121.84,,,percent of total billed charges,,,141.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE LS 4 PLUS VW,3224797,CDM,320,RC,72110,CPT,5522,APC,,,,outpatient,facility,,,156,156,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE LS 2 3 VW,3224805,CDM,320,RC,72100,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE LS 2 3 VW,3224805,CDM,320,RC,72100,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE LS 2 3 VW,3224805,CDM,320,RC,72100,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE THORACIC 4 PLUS VW,3224854,CDM,320,RC,72074,CPT,,,,,,inpatient,facility,,,130,54.6,110.5,124.8,,110.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.1,,,percent of total billed charges,,,,,,,,,117,,,percent of total billed charges,,,124.8,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,120.9,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACIC 4 PLUS VW,3224854,CDM,320,RC,72074,CPT,,,,,,outpatient,facility,,,130,54.6,35.1,124.8,,110.5,,,percent of total billed charges,,,35.1,,,percent of total billed charges,,,89.44,,,percent of total billed charges,,,87.49,,,percent of total billed charges,,,109.85,,,percent of total billed charges,,,,,,,,,113.1,,,percent of total billed charges,,,113.1,,,percent of total billed charges,,,110.5,,,percent of total billed charges,,,124.8,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,,,,,,,117,,,percent of total billed charges,,,,,,,,,120.9,,,percent of total billed charges,,,123.5,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,101.53,,,percent of total billed charges,,,118.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACIC 4 PLUS VW,3224854,CDM,320,RC,72074,CPT,5522,APC,,,,outpatient,facility,,,130,130,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE THORACIC 2 VW,3224862,CDM,320,RC,72070,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACIC 2 VW,3224862,CDM,320,RC,72070,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACIC 2 VW,3224862,CDM,320,RC,72070,CPT,5522,APC,,,,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE THORACIC 3 VW,3224870,CDM,320,RC,72072,CPT,,,,,,inpatient,facility,,,118,49.56,100.3,113.28,,100.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,102.66,,,percent of total billed charges,,,,,,,,,106.2,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACIC 3 VW,3224870,CDM,320,RC,72072,CPT,,,,,,outpatient,facility,,,118,49.56,31.86,113.28,,100.3,,,percent of total billed charges,,,31.86,,,percent of total billed charges,,,81.18,,,percent of total billed charges,,,79.41,,,percent of total billed charges,,,99.71,,,percent of total billed charges,,,,,,,,,102.66,,,percent of total billed charges,,,102.66,,,percent of total billed charges,,,100.3,,,percent of total billed charges,,,113.28,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,106.2,,,percent of total billed charges,,,,,,,,,109.74,,,percent of total billed charges,,,112.1,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,92.16,,,percent of total billed charges,,,107.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACIC 3 VW,3224870,CDM,320,RC,72072,CPT,5522,APC,,,,outpatient,facility,,,118,118,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE THORACOLUMBAR  EQLS MORE THAN 2 VW,3224888,CDM,320,RC,72080,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACOLUMBAR  EQLS MORE THAN 2 VW,3224888,CDM,320,RC,72080,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE THORACOLUMBAR  EQLS MORE THAN 2 VW,3224888,CDM,320,RC,72080,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR JT S STERNOCLAVICULAR 3 PLUS VW,3224920,CDM,320,RC,71130,CPT,,,,,,inpatient,facility,,,132,55.44,112.2,126.72,,112.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.84,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,126.72,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,122.76,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR JT S STERNOCLAVICULAR 3 PLUS VW,3224920,CDM,320,RC,71130,CPT,,,,,,outpatient,facility,,,132,55.44,35.64,126.72,,112.2,,,percent of total billed charges,,,35.64,,,percent of total billed charges,,,90.82,,,percent of total billed charges,,,88.84,,,percent of total billed charges,,,111.54,,,percent of total billed charges,,,,,,,,,114.84,,,percent of total billed charges,,,114.84,,,percent of total billed charges,,,112.2,,,percent of total billed charges,,,126.72,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,118.8,,,percent of total billed charges,,,,,,,,,122.76,,,percent of total billed charges,,,125.4,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,103.09,,,percent of total billed charges,,,120.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR JT S STERNOCLAVICULAR 3 PLUS VW,3224920,CDM,320,RC,71130,CPT,5521,APC,,,,outpatient,facility,,,132,132,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR STERNUM 2 PLUS VW,3224938,CDM,320,RC,71120,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR STERNUM 2 PLUS VW,3224938,CDM,320,RC,71120,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR STERNUM 2 PLUS VW,3224938,CDM,320,RC,71120,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
OCC EV ART BLN TEMP CNS W ANG,3224995,CDM,361,RC,61623,CPT,,,,,,inpatient,facility,,,7555,3173.1,6421.75,7252.8,,6421.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6572.85,,,percent of total billed charges,,,,,,,,,6799.5,,,percent of total billed charges,,,7252.8,,,percent of total billed charges,,,7177.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7026.15,,,percent of total billed charges,,,7177.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
OCC EV ART BLN TEMP CNS W ANG,3224995,CDM,361,RC,61623,CPT,,,,,,outpatient,facility,,,7555,3173.1,2039.85,29580,,6421.75,,,percent of total billed charges,,,2039.85,,,percent of total billed charges,,,5197.84,,,percent of total billed charges,,,5084.51,,,percent of total billed charges,,,6383.97,,,percent of total billed charges,,,,,,,,,6572.85,,,percent of total billed charges,,,6572.85,,,percent of total billed charges,,,6421.75,,,percent of total billed charges,,,7252.8,,,percent of total billed charges,,,7177.25,,,percent of total billed charges,,,,,,,,,6799.5,,,percent of total billed charges,,,,,,,,,7026.15,,,percent of total billed charges,,,7177.25,,,percent of total billed charges,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,11001.5,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,6875.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
OCC EV ART BLN TEMP CNS W ANG,3224995,CDM,361,RC,61623,CPT,5193,APC,,,,outpatient,facility,,,7555,7555,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TIBIA ANDFIBULA 2 VW LT,3225091,CDM,320,RC,73590,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW LT,3225091,CDM,320,RC,73590,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW LT,3225091,CDM,320,RC,73590,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TIBIA ANDFIBULA 2 VW RT,3225109,CDM,320,RC,73590,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW RT,3225109,CDM,320,RC,73590,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW RT,3225109,CDM,320,RC,73590,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INTRO NDL AORTA TRANSLUMBAR,3225117,CDM,361,RC,36160,CPT,,,,,,inpatient,facility,,,1000,420,850,960,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO NDL AORTA TRANSLUMBAR,3225117,CDM,361,RC,36160,CPT,,,,,,outpatient,facility,,,1000,420,270,3428,,850,,,percent of total billed charges,,,270,,,percent of total billed charges,,,688,,,percent of total billed charges,,,673,,,percent of total billed charges,,,845,,,percent of total billed charges,,,,,,,,,870,,,percent of total billed charges,,,870,,,percent of total billed charges,,,850,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,1000,,,fee schedule,,,1000,,,fee schedule,,,1000,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TMJ MOUTH OPEN ANDCLOSE BI,3225125,CDM,320,RC,70330,CPT,,,,,,inpatient,facility,,,247,103.74,209.95,237.12,,209.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,214.89,,,percent of total billed charges,,,,,,,,,222.3,,,percent of total billed charges,,,237.12,,,percent of total billed charges,,,234.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,229.71,,,percent of total billed charges,,,234.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TMJ MOUTH OPEN ANDCLOSE BI,3225125,CDM,320,RC,70330,CPT,,,,,,outpatient,facility,,,247,103.74,66.69,237.12,,209.95,,,percent of total billed charges,,,66.69,,,percent of total billed charges,,,169.94,,,percent of total billed charges,,,166.23,,,percent of total billed charges,,,208.72,,,percent of total billed charges,,,,,,,,,214.89,,,percent of total billed charges,,,214.89,,,percent of total billed charges,,,209.95,,,percent of total billed charges,,,237.12,,,percent of total billed charges,,,234.65,,,percent of total billed charges,,,,,,,,,222.3,,,percent of total billed charges,,,,,,,,,229.71,,,percent of total billed charges,,,234.65,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,192.91,,,percent of total billed charges,,,224.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TMJ MOUTH OPEN ANDCLOSE BI,3225125,CDM,320,RC,70330,CPT,5521,APC,,,,outpatient,facility,,,247,247,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TMJ MOUTH OPEN ANDCLOSE LT,3225133,CDM,320,RC,70328,CPT,,,,,LT  ,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TMJ MOUTH OPEN ANDCLOSE LT,3225133,CDM,320,RC,70328,CPT,,,,,LT  ,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,,,,,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TMJ MOUTH OPEN ANDCLOSE LT,3225133,CDM,320,RC,70328,CPT,5521,APC,,,LT  ,outpatient,facility,,,106,106,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TMJ MOUTH OPEN ANDCLOSE RT,3225141,CDM,320,RC,70328,CPT,,,,,RT  ,inpatient,facility,,,106,44.52,90.1,101.76,,90.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.22,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TMJ MOUTH OPEN ANDCLOSE RT,3225141,CDM,320,RC,70328,CPT,,,,,RT  ,outpatient,facility,,,106,44.52,28.62,101.76,,90.1,,,percent of total billed charges,,,28.62,,,percent of total billed charges,,,72.93,,,percent of total billed charges,,,71.34,,,percent of total billed charges,,,89.57,,,percent of total billed charges,,,,,,,,,92.22,,,percent of total billed charges,,,92.22,,,percent of total billed charges,,,90.1,,,percent of total billed charges,,,101.76,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,95.4,,,percent of total billed charges,,,,,,,,,98.58,,,percent of total billed charges,,,100.7,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,82.79,,,percent of total billed charges,,,96.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TMJ MOUTH OPEN ANDCLOSE RT,3225141,CDM,320,RC,70328,CPT,5521,APC,,,RT  ,outpatient,facility,,,106,106,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TOMOGRAPHY SGL EXCEPT URO,3225158,CDM,320,RC,76100,CPT,,,,,,inpatient,facility,,,184,77.28,156.4,176.64,,156.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.08,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TOMOGRAPHY SGL EXCEPT URO,3225158,CDM,320,RC,76100,CPT,,,,,,outpatient,facility,,,184,77.28,49.68,176.64,,156.4,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,126.59,,,percent of total billed charges,,,123.83,,,percent of total billed charges,,,155.48,,,percent of total billed charges,,,,,,,,,160.08,,,percent of total billed charges,,,160.08,,,percent of total billed charges,,,156.4,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,143.7,,,percent of total billed charges,,,167.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TOMOGRAPHY SGL EXCEPT URO,3225158,CDM,320,RC,76100,CPT,5522,APC,,,,outpatient,facility,,,184,184,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THERAPY TRANSCATH EMB S ANDI,3225190,CDM,320,RC,75894,CPT,,,,,,inpatient,facility,,,1776,745.92,1509.6,1704.96,,1509.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1545.12,,,percent of total billed charges,,,,,,,,,1598.4,,,percent of total billed charges,,,1704.96,,,percent of total billed charges,,,1687.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1651.68,,,percent of total billed charges,,,1687.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY TRANSCATH EMB S ANDI,3225190,CDM,320,RC,75894,CPT,,,,,,outpatient,facility,,,1776,745.92,479.52,1776,,1509.6,,,percent of total billed charges,,,479.52,,,percent of total billed charges,,,1221.89,,,percent of total billed charges,,,1195.25,,,percent of total billed charges,,,1500.72,,,percent of total billed charges,,,,,,,,,1545.12,,,percent of total billed charges,,,1545.12,,,percent of total billed charges,,,1509.6,,,percent of total billed charges,,,1704.96,,,percent of total billed charges,,,1687.2,,,percent of total billed charges,,,,,,,,,1598.4,,,percent of total billed charges,,,,,,,,,1651.68,,,percent of total billed charges,,,1687.2,,,percent of total billed charges,,,,,,,,,,,,,,,1776,,,fee schedule,,,1776,,,fee schedule,,,1776,,,fee schedule,,,,,,,,,1387.06,,,percent of total billed charges,,,1616.16,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL STRICT DUCT BILI TRANSHEP S ANDI,3225216,CDM,320,RC,74363,CPT,,,,,,inpatient,facility,,,1479,621.18,1257.15,1419.84,,1257.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1286.73,,,percent of total billed charges,,,,,,,,,1331.1,,,percent of total billed charges,,,1419.84,,,percent of total billed charges,,,1405.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1375.47,,,percent of total billed charges,,,1405.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL STRICT DUCT BILI TRANSHEP S ANDI,3225216,CDM,320,RC,74363,CPT,,,,,,outpatient,facility,,,1479,621.18,399.33,1479,,1257.15,,,percent of total billed charges,,,399.33,,,percent of total billed charges,,,1017.55,,,percent of total billed charges,,,995.37,,,percent of total billed charges,,,1249.75,,,percent of total billed charges,,,,,,,,,1286.73,,,percent of total billed charges,,,1286.73,,,percent of total billed charges,,,1257.15,,,percent of total billed charges,,,1419.84,,,percent of total billed charges,,,1405.05,,,percent of total billed charges,,,,,,,,,1331.1,,,percent of total billed charges,,,,,,,,,1375.47,,,percent of total billed charges,,,1405.05,,,percent of total billed charges,,,,,,,,,,,,,,,1479,,,fee schedule,,,1479,,,fee schedule,,,1479,,,fee schedule,,,,,,,,,1155.1,,,percent of total billed charges,,,1345.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR EXT UPPER INFANT 2 PLUS VW LT,3225299,CDM,320,RC,73092,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR EXT UPPER INFANT 2 PLUS VW LT,3225299,CDM,320,RC,73092,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR EXT UPPER INFANT 2 PLUS VW LT,3225299,CDM,320,RC,73092,CPT,5522,APC,,,LT  ,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR EXT UPPER INFANT 2 PLUS VW RT,3225307,CDM,320,RC,73092,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR EXT UPPER INFANT 2 PLUS VW RT,3225307,CDM,320,RC,73092,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,112.19,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR EXT UPPER INFANT 2 PLUS VW RT,3225307,CDM,320,RC,73092,CPT,5522,APC,,,RT  ,outpatient,facility,,,111,111,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
URETHROCYSTOGRAM RETROGRADE S ANDI,3225323,CDM,320,RC,74450,CPT,,,,,,inpatient,facility,,,519,217.98,441.15,498.24,,441.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,451.53,,,percent of total billed charges,,,,,,,,,467.1,,,percent of total billed charges,,,498.24,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,482.67,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
URETHROCYSTOGRAM RETROGRADE S ANDI,3225323,CDM,320,RC,74450,CPT,,,,,,outpatient,facility,,,519,217.98,140.13,498.24,,441.15,,,percent of total billed charges,,,140.13,,,percent of total billed charges,,,357.07,,,percent of total billed charges,,,349.29,,,percent of total billed charges,,,438.56,,,percent of total billed charges,,,,,,,,,451.53,,,percent of total billed charges,,,451.53,,,percent of total billed charges,,,441.15,,,percent of total billed charges,,,498.24,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,467.1,,,percent of total billed charges,,,,,,,,,482.67,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,405.34,,,percent of total billed charges,,,472.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
URETHROCYSTOGRAM RETROGRADE S ANDI,3225323,CDM,320,RC,74450,CPT,5523,APC,,,,outpatient,facility,,,519,519,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
URETHROCYSTOGRAM VOIDING S ANDI,3225331,CDM,320,RC,74455,CPT,,,,,,inpatient,facility,,,519,217.98,441.15,498.24,,441.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,451.53,,,percent of total billed charges,,,,,,,,,467.1,,,percent of total billed charges,,,498.24,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,482.67,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
URETHROCYSTOGRAM VOIDING S ANDI,3225331,CDM,320,RC,74455,CPT,,,,,,outpatient,facility,,,519,217.98,140.13,498.24,,441.15,,,percent of total billed charges,,,140.13,,,percent of total billed charges,,,357.07,,,percent of total billed charges,,,349.29,,,percent of total billed charges,,,438.56,,,percent of total billed charges,,,,,,,,,451.53,,,percent of total billed charges,,,451.53,,,percent of total billed charges,,,441.15,,,percent of total billed charges,,,498.24,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,467.1,,,percent of total billed charges,,,,,,,,,482.67,,,percent of total billed charges,,,493.05,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,405.34,,,percent of total billed charges,,,472.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
URETHROCYSTOGRAM VOIDING S ANDI,3225331,CDM,320,RC,74455,CPT,5523,APC,,,,outpatient,facility,,,519,519,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
UROGRAPHY INF AND BOLUS,3225356,CDM,320,RC,74410,CPT,,,,,,inpatient,facility,,,1107,464.94,940.95,1062.72,,940.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,963.09,,,percent of total billed charges,,,,,,,,,996.3,,,percent of total billed charges,,,1062.72,,,percent of total billed charges,,,1051.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1029.51,,,percent of total billed charges,,,1051.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
UROGRAPHY INF AND BOLUS,3225356,CDM,320,RC,74410,CPT,,,,,,outpatient,facility,,,1107,464.94,183.74,1062.72,,940.95,,,percent of total billed charges,,,298.89,,,percent of total billed charges,,,761.62,,,percent of total billed charges,,,745.01,,,percent of total billed charges,,,935.41,,,percent of total billed charges,,,,,,,,,963.09,,,percent of total billed charges,,,963.09,,,percent of total billed charges,,,940.95,,,percent of total billed charges,,,1062.72,,,percent of total billed charges,,,1051.65,,,percent of total billed charges,,,,,,,,,996.3,,,percent of total billed charges,,,,,,,,,1029.51,,,percent of total billed charges,,,1051.65,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,864.57,,,percent of total billed charges,,,1007.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
UROGRAPHY INF AND BOLUS,3225356,CDM,320,RC,74410,CPT,5571,APC,,,,outpatient,facility,,,1107,1107,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
UROGRAPHY RETROGRADE W WO KUB,3225364,CDM,320,RC,74420,CPT,,,,,,inpatient,facility,,,530,222.6,450.5,508.8,,450.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.1,,,percent of total billed charges,,,,,,,,,477,,,percent of total billed charges,,,508.8,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.9,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
UROGRAPHY RETROGRADE W WO KUB,3225364,CDM,320,RC,74420,CPT,,,,,,outpatient,facility,,,530,222.6,143.1,508.8,,450.5,,,percent of total billed charges,,,143.1,,,percent of total billed charges,,,364.64,,,percent of total billed charges,,,356.69,,,percent of total billed charges,,,447.85,,,percent of total billed charges,,,,,,,,,461.1,,,percent of total billed charges,,,461.1,,,percent of total billed charges,,,450.5,,,percent of total billed charges,,,508.8,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,477,,,percent of total billed charges,,,,,,,,,492.9,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,413.93,,,percent of total billed charges,,,482.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
UROGRAPHY RETROGRADE W WO KUB,3225364,CDM,320,RC,74420,CPT,5572,APC,,,,outpatient,facility,,,530,530,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM HEPATIC W EVAL HEMO S ANDI,3225455,CDM,320,RC,75889,CPT,,,,,,inpatient,facility,,,5171,2171.82,4395.35,4964.16,,4395.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4498.77,,,percent of total billed charges,,,,,,,,,4653.9,,,percent of total billed charges,,,4964.16,,,percent of total billed charges,,,4912.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4809.03,,,percent of total billed charges,,,4912.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM HEPATIC W EVAL HEMO S ANDI,3225455,CDM,320,RC,75889,CPT,,,,,,outpatient,facility,,,5171,2171.82,1396.17,4964.16,,4395.35,,,percent of total billed charges,,,1396.17,,,percent of total billed charges,,,3557.65,,,percent of total billed charges,,,3480.08,,,percent of total billed charges,,,4369.49,,,percent of total billed charges,,,,,,,,,4498.77,,,percent of total billed charges,,,4498.77,,,percent of total billed charges,,,4395.35,,,percent of total billed charges,,,4964.16,,,percent of total billed charges,,,4912.45,,,percent of total billed charges,,,,,,,,,4653.9,,,percent of total billed charges,,,,,,,,,4809.03,,,percent of total billed charges,,,4912.45,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4038.55,,,percent of total billed charges,,,4705.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM HEPATIC W EVAL HEMO S ANDI,3225455,CDM,320,RC,75889,CPT,5183,APC,,,,outpatient,facility,,,5171,5171,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM HEPATIC WO EVAL HEMO S ANDI,3225463,CDM,320,RC,75891,CPT,,,,,,inpatient,facility,,,5223,2193.66,4439.55,5014.08,,4439.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4544.01,,,percent of total billed charges,,,,,,,,,4700.7,,,percent of total billed charges,,,5014.08,,,percent of total billed charges,,,4961.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4857.39,,,percent of total billed charges,,,4961.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM HEPATIC WO EVAL HEMO S ANDI,3225463,CDM,320,RC,75891,CPT,,,,,,outpatient,facility,,,5223,2193.66,1410.21,5014.08,,4439.55,,,percent of total billed charges,,,1410.21,,,percent of total billed charges,,,3593.42,,,percent of total billed charges,,,3515.08,,,percent of total billed charges,,,4413.43,,,percent of total billed charges,,,,,,,,,4544.01,,,percent of total billed charges,,,4544.01,,,percent of total billed charges,,,4439.55,,,percent of total billed charges,,,5014.08,,,percent of total billed charges,,,4961.85,,,percent of total billed charges,,,,,,,,,4700.7,,,percent of total billed charges,,,,,,,,,4857.39,,,percent of total billed charges,,,4961.85,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4079.16,,,percent of total billed charges,,,4752.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM HEPATIC WO EVAL HEMO S ANDI,3225463,CDM,320,RC,75891,CPT,5183,APC,,,,outpatient,facility,,,5223,5223,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM IVC SERIAL S ANDI,3225471,CDM,320,RC,75825,CPT,,,,,,inpatient,facility,,,6101,2562.42,5185.85,5856.96,,5185.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5307.87,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM IVC SERIAL S ANDI,3225471,CDM,320,RC,75825,CPT,,,,,,outpatient,facility,,,6101,2562.42,1647.27,5856.96,,5185.85,,,percent of total billed charges,,,1647.27,,,percent of total billed charges,,,4197.49,,,percent of total billed charges,,,4105.97,,,percent of total billed charges,,,5155.35,,,percent of total billed charges,,,,,,,,,5307.87,,,percent of total billed charges,,,5307.87,,,percent of total billed charges,,,5185.85,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4764.88,,,percent of total billed charges,,,5551.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM IVC SERIAL S ANDI,3225471,CDM,320,RC,75825,CPT,5183,APC,,,,outpatient,facility,,,6101,6101,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM SINUS VEN JUG S ANDI,3225489,CDM,320,RC,75860,CPT,,,,,,inpatient,facility,,,2223,933.66,1889.55,2134.08,,1889.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1934.01,,,percent of total billed charges,,,,,,,,,2000.7,,,percent of total billed charges,,,2134.08,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2067.39,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM SINUS VEN JUG S ANDI,3225489,CDM,320,RC,75860,CPT,,,,,,outpatient,facility,,,2223,933.66,600.21,3252.64,,1889.55,,,percent of total billed charges,,,600.21,,,percent of total billed charges,,,1529.42,,,percent of total billed charges,,,1496.08,,,percent of total billed charges,,,1878.43,,,percent of total billed charges,,,,,,,,,1934.01,,,percent of total billed charges,,,1934.01,,,percent of total billed charges,,,1889.55,,,percent of total billed charges,,,2134.08,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,2000.7,,,percent of total billed charges,,,,,,,,,2067.39,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,1736.16,,,percent of total billed charges,,,2022.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM SINUS VEN JUG S ANDI,3225489,CDM,320,RC,75860,CPT,5183,APC,,,,outpatient,facility,,,2223,2223,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM RENAL SEL BI S ANDI,3225505,CDM,320,RC,75833,CPT,,,,,,inpatient,facility,,,9138,3837.96,7767.3,8772.48,,7767.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7950.06,,,percent of total billed charges,,,,,,,,,8224.2,,,percent of total billed charges,,,8772.48,,,percent of total billed charges,,,8681.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8498.34,,,percent of total billed charges,,,8681.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM RENAL SEL BI S ANDI,3225505,CDM,320,RC,75833,CPT,,,,,,outpatient,facility,,,9138,3837.96,2467.26,8772.48,,7767.3,,,percent of total billed charges,,,2467.26,,,percent of total billed charges,,,6286.94,,,percent of total billed charges,,,6149.87,,,percent of total billed charges,,,7721.61,,,percent of total billed charges,,,,,,,,,7950.06,,,percent of total billed charges,,,7950.06,,,percent of total billed charges,,,7767.3,,,percent of total billed charges,,,8772.48,,,percent of total billed charges,,,8681.1,,,percent of total billed charges,,,,,,,,,8224.2,,,percent of total billed charges,,,,,,,,,8498.34,,,percent of total billed charges,,,8681.1,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,7136.78,,,percent of total billed charges,,,8315.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM RENAL SEL BI S ANDI,3225505,CDM,320,RC,75833,CPT,5183,APC,,,,outpatient,facility,,,9138,9138,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM RENAL SEL LT S ANDI,3225513,CDM,320,RC,75831,CPT,,,,,LT  ,inpatient,facility,,,5163,2168.46,4388.55,4956.48,,4388.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4491.81,,,percent of total billed charges,,,,,,,,,4646.7,,,percent of total billed charges,,,4956.48,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4801.59,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM RENAL SEL LT S ANDI,3225513,CDM,320,RC,75831,CPT,,,,,LT  ,outpatient,facility,,,5163,2168.46,1394.01,5163,,4388.55,,,percent of total billed charges,,,1394.01,,,percent of total billed charges,,,3552.14,,,percent of total billed charges,,,3474.7,,,percent of total billed charges,,,4362.73,,,percent of total billed charges,,,,,,,,,4491.81,,,percent of total billed charges,,,4491.81,,,percent of total billed charges,,,4388.55,,,percent of total billed charges,,,4956.48,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,4646.7,,,percent of total billed charges,,,,,,,,,4801.59,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,,,,,,,5163,,,fee schedule,,,5163,,,fee schedule,,,5163,,,fee schedule,,,,,,,,,4032.3,,,percent of total billed charges,,,4698.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM RENAL SEL LT S ANDI,3225513,CDM,320,RC,75831,CPT,5183,APC,,,LT  ,outpatient,facility,,,5163,5163,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM RENAL SEL RT S ANDI,3225521,CDM,320,RC,75831,CPT,,,,,RT  ,inpatient,facility,,,5163,2168.46,4388.55,4956.48,,4388.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4491.81,,,percent of total billed charges,,,,,,,,,4646.7,,,percent of total billed charges,,,4956.48,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4801.59,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM RENAL SEL RT S ANDI,3225521,CDM,320,RC,75831,CPT,,,,,RT  ,outpatient,facility,,,5163,2168.46,1394.01,5163,,4388.55,,,percent of total billed charges,,,1394.01,,,percent of total billed charges,,,3552.14,,,percent of total billed charges,,,3474.7,,,percent of total billed charges,,,4362.73,,,percent of total billed charges,,,,,,,,,4491.81,,,percent of total billed charges,,,4491.81,,,percent of total billed charges,,,4388.55,,,percent of total billed charges,,,4956.48,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,4646.7,,,percent of total billed charges,,,,,,,,,4801.59,,,percent of total billed charges,,,4904.85,,,percent of total billed charges,,,,,,,,,,,,,,,5163,,,fee schedule,,,5163,,,fee schedule,,,5163,,,fee schedule,,,,,,,,,4032.3,,,percent of total billed charges,,,4698.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM RENAL SEL RT S ANDI,3225521,CDM,320,RC,75831,CPT,5183,APC,,,RT  ,outpatient,facility,,,5163,5163,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM SINUS SAGITTAL SUP S ANDI,3225539,CDM,320,RC,75870,CPT,,,,,,inpatient,facility,,,2223,933.66,1889.55,2134.08,,1889.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1934.01,,,percent of total billed charges,,,,,,,,,2000.7,,,percent of total billed charges,,,2134.08,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2067.39,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM SINUS SAGITTAL SUP S ANDI,3225539,CDM,320,RC,75870,CPT,,,,,,outpatient,facility,,,2223,933.66,600.21,2223,,1889.55,,,percent of total billed charges,,,600.21,,,percent of total billed charges,,,1529.42,,,percent of total billed charges,,,1496.08,,,percent of total billed charges,,,1878.43,,,percent of total billed charges,,,,,,,,,1934.01,,,percent of total billed charges,,,1934.01,,,percent of total billed charges,,,1889.55,,,percent of total billed charges,,,2134.08,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,2000.7,,,percent of total billed charges,,,,,,,,,2067.39,,,percent of total billed charges,,,2111.85,,,percent of total billed charges,,,,,,,,,,,,,,,2223,,,fee schedule,,,2223,,,fee schedule,,,2223,,,fee schedule,,,,,,,,,1736.16,,,percent of total billed charges,,,2022.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM SINUS SAGITTAL SUP S ANDI,3225539,CDM,320,RC,75870,CPT,5183,APC,,,,outpatient,facility,,,2223,2223,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CATH VENOUS SAMPLE BLOOD ORGAN,3225570,CDM,361,RC,36500,CPT,,,,,,inpatient,facility,,,874,367.08,742.9,839.04,,742.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,760.38,,,percent of total billed charges,,,,,,,,,786.6,,,percent of total billed charges,,,839.04,,,percent of total billed charges,,,830.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,812.82,,,percent of total billed charges,,,830.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CATH VENOUS SAMPLE BLOOD ORGAN,3225570,CDM,361,RC,36500,CPT,,,,,,outpatient,facility,,,874,367.08,235.98,3428,,742.9,,,percent of total billed charges,,,235.98,,,percent of total billed charges,,,601.31,,,percent of total billed charges,,,588.2,,,percent of total billed charges,,,738.53,,,percent of total billed charges,,,,,,,,,760.38,,,percent of total billed charges,,,760.38,,,percent of total billed charges,,,742.9,,,percent of total billed charges,,,839.04,,,percent of total billed charges,,,830.3,,,percent of total billed charges,,,,,,,,,786.6,,,percent of total billed charges,,,,,,,,,812.82,,,percent of total billed charges,,,830.3,,,percent of total billed charges,,,,,,,,,,,,,,,874,,,fee schedule,,,874,,,fee schedule,,,874,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,795.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SAMPLE VENOUS CATH W WO ANG S ANDI,3225588,CDM,320,RC,75893,CPT,,,,,,inpatient,facility,,,5105,2144.1,4339.25,4900.8,,4339.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4441.35,,,percent of total billed charges,,,,,,,,,4594.5,,,percent of total billed charges,,,4900.8,,,percent of total billed charges,,,4849.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4747.65,,,percent of total billed charges,,,4849.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SAMPLE VENOUS CATH W WO ANG S ANDI,3225588,CDM,320,RC,75893,CPT,,,,,,outpatient,facility,,,5105,2144.1,1378.35,5607.67,,4339.25,,,percent of total billed charges,,,1378.35,,,percent of total billed charges,,,3512.24,,,percent of total billed charges,,,3435.66,,,percent of total billed charges,,,4313.72,,,percent of total billed charges,,,,,,,,,4441.35,,,percent of total billed charges,,,4441.35,,,percent of total billed charges,,,4339.25,,,percent of total billed charges,,,4900.8,,,percent of total billed charges,,,4849.75,,,percent of total billed charges,,,,,,,,,4594.5,,,percent of total billed charges,,,,,,,,,4747.65,,,percent of total billed charges,,,4849.75,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,3987.01,,,percent of total billed charges,,,4645.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SAMPLE VENOUS CATH W WO ANG S ANDI,3225588,CDM,320,RC,75893,CPT,5184,APC,,,,outpatient,facility,,,5105,5105,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR WRIST CMP 3 PLUS VW LT,3225620,CDM,320,RC,73110,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR WRIST CMP 3 PLUS VW LT,3225620,CDM,320,RC,73110,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR WRIST CMP 3 PLUS VW LT,3225620,CDM,320,RC,73110,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR WRIST CMP 3 PLUS VW RT,3225638,CDM,320,RC,73110,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR WRIST CMP 3 PLUS VW RT,3225638,CDM,320,RC,73110,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR WRIST CMP 3 PLUS VW RT,3225638,CDM,320,RC,73110,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR WRIST 2 VW LT,3225653,CDM,320,RC,73100,CPT,,,,,LT  ,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW LT,3225653,CDM,320,RC,73100,CPT,,,,,LT  ,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW LT,3225653,CDM,320,RC,73100,CPT,5521,APC,,,LT  ,outpatient,facility,,,97,97,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR WRIST 2 VW RT,3225661,CDM,320,RC,73100,CPT,,,,,RT  ,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW RT,3225661,CDM,320,RC,73100,CPT,,,,,RT  ,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW RT,3225661,CDM,320,RC,73100,CPT,5521,APC,,,RT  ,outpatient,facility,,,97,97,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO SHOULDER LT S ANDI,3225687,CDM,322,RC,73040,CPT,,,,,LT  ,inpatient,facility,,,787,330.54,668.95,755.52,,668.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.69,,,percent of total billed charges,,,,,,,,,708.3,,,percent of total billed charges,,,755.52,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,731.91,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO SHOULDER LT S ANDI,3225687,CDM,322,RC,73040,CPT,,,,,LT  ,outpatient,facility,,,787,330.54,212.49,755.52,,668.95,,,percent of total billed charges,,,212.49,,,percent of total billed charges,,,541.46,,,percent of total billed charges,,,529.65,,,percent of total billed charges,,,665.01,,,percent of total billed charges,,,,,,,,,684.69,,,percent of total billed charges,,,684.69,,,percent of total billed charges,,,668.95,,,percent of total billed charges,,,755.52,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,708.3,,,percent of total billed charges,,,,,,,,,731.91,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,614.65,,,percent of total billed charges,,,716.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO SHOULDER LT S ANDI,3225687,CDM,322,RC,73040,CPT,5572,APC,,,LT  ,outpatient,facility,,,787,787,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO SHOULDER RT S ANDI,3225695,CDM,322,RC,73040,CPT,,,,,RT  ,inpatient,facility,,,787,330.54,668.95,755.52,,668.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,684.69,,,percent of total billed charges,,,,,,,,,708.3,,,percent of total billed charges,,,755.52,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,731.91,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO SHOULDER RT S ANDI,3225695,CDM,322,RC,73040,CPT,,,,,RT  ,outpatient,facility,,,787,330.54,212.49,755.52,,668.95,,,percent of total billed charges,,,212.49,,,percent of total billed charges,,,541.46,,,percent of total billed charges,,,529.65,,,percent of total billed charges,,,665.01,,,percent of total billed charges,,,,,,,,,684.69,,,percent of total billed charges,,,684.69,,,percent of total billed charges,,,668.95,,,percent of total billed charges,,,755.52,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,708.3,,,percent of total billed charges,,,,,,,,,731.91,,,percent of total billed charges,,,747.65,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,614.65,,,percent of total billed charges,,,716.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO SHOULDER RT S ANDI,3225695,CDM,322,RC,73040,CPT,5572,APC,,,RT  ,outpatient,facility,,,787,787,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO ANKLE LT S ANDI,3225703,CDM,322,RC,73615,CPT,,,,,LT  ,inpatient,facility,,,671,281.82,570.35,644.16,,570.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.77,,,percent of total billed charges,,,,,,,,,603.9,,,percent of total billed charges,,,644.16,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,624.03,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ANKLE LT S ANDI,3225703,CDM,322,RC,73615,CPT,,,,,LT  ,outpatient,facility,,,671,281.82,181.17,644.16,,570.35,,,percent of total billed charges,,,181.17,,,percent of total billed charges,,,461.65,,,percent of total billed charges,,,451.58,,,percent of total billed charges,,,567,,,percent of total billed charges,,,,,,,,,583.77,,,percent of total billed charges,,,583.77,,,percent of total billed charges,,,570.35,,,percent of total billed charges,,,644.16,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,603.9,,,percent of total billed charges,,,,,,,,,624.03,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,524.05,,,percent of total billed charges,,,610.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ANKLE LT S ANDI,3225703,CDM,322,RC,73615,CPT,5572,APC,,,LT  ,outpatient,facility,,,671,671,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO ANKLE RT S ANDI,3225711,CDM,322,RC,73615,CPT,,,,,RT  ,inpatient,facility,,,671,281.82,570.35,644.16,,570.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,583.77,,,percent of total billed charges,,,,,,,,,603.9,,,percent of total billed charges,,,644.16,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,624.03,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ANKLE RT S ANDI,3225711,CDM,322,RC,73615,CPT,,,,,RT  ,outpatient,facility,,,671,281.82,181.17,644.16,,570.35,,,percent of total billed charges,,,181.17,,,percent of total billed charges,,,461.65,,,percent of total billed charges,,,451.58,,,percent of total billed charges,,,567,,,percent of total billed charges,,,,,,,,,583.77,,,percent of total billed charges,,,583.77,,,percent of total billed charges,,,570.35,,,percent of total billed charges,,,644.16,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,603.9,,,percent of total billed charges,,,,,,,,,624.03,,,percent of total billed charges,,,637.45,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,524.05,,,percent of total billed charges,,,610.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ANKLE RT S ANDI,3225711,CDM,322,RC,73615,CPT,5572,APC,,,RT  ,outpatient,facility,,,671,671,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO ELBOW LT S ANDI,3225729,CDM,322,RC,73085,CPT,,,,,LT  ,inpatient,facility,,,450,189,382.5,432,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ELBOW LT S ANDI,3225729,CDM,322,RC,73085,CPT,,,,,LT  ,outpatient,facility,,,450,189,121.5,432,,382.5,,,percent of total billed charges,,,121.5,,,percent of total billed charges,,,309.6,,,percent of total billed charges,,,302.85,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,,382.5,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,351.45,,,percent of total billed charges,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ELBOW LT S ANDI,3225729,CDM,322,RC,73085,CPT,5572,APC,,,LT  ,outpatient,facility,,,450,450,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO ELBOW RT S ANDI,3225737,CDM,322,RC,73085,CPT,,,,,RT  ,inpatient,facility,,,450,189,382.5,432,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ELBOW RT S ANDI,3225737,CDM,322,RC,73085,CPT,,,,,RT  ,outpatient,facility,,,450,189,121.5,432,,382.5,,,percent of total billed charges,,,121.5,,,percent of total billed charges,,,309.6,,,percent of total billed charges,,,302.85,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,,382.5,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,351.45,,,percent of total billed charges,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO ELBOW RT S ANDI,3225737,CDM,322,RC,73085,CPT,5572,APC,,,RT  ,outpatient,facility,,,450,450,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO HIP LT S ANDI,3225745,CDM,322,RC,73525,CPT,,,,,LT  ,inpatient,facility,,,450,189,382.5,432,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO HIP LT S ANDI,3225745,CDM,322,RC,73525,CPT,,,,,LT  ,outpatient,facility,,,450,189,121.5,432,,382.5,,,percent of total billed charges,,,121.5,,,percent of total billed charges,,,309.6,,,percent of total billed charges,,,302.85,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,,382.5,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,351.45,,,percent of total billed charges,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO HIP LT S ANDI,3225745,CDM,322,RC,73525,CPT,5572,APC,,,LT  ,outpatient,facility,,,450,450,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO HIP RT S ANDI,3225752,CDM,322,RC,73525,CPT,,,,,RT  ,inpatient,facility,,,450,189,382.5,432,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO HIP RT S ANDI,3225752,CDM,322,RC,73525,CPT,,,,,RT  ,outpatient,facility,,,450,189,121.5,432,,382.5,,,percent of total billed charges,,,121.5,,,percent of total billed charges,,,309.6,,,percent of total billed charges,,,302.85,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,,382.5,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,351.45,,,percent of total billed charges,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO HIP RT S ANDI,3225752,CDM,322,RC,73525,CPT,5572,APC,,,RT  ,outpatient,facility,,,450,450,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO KNEE LT S ANDI,3225760,CDM,322,RC,73580,CPT,,,,,LT  ,inpatient,facility,,,486,204.12,413.1,466.56,,413.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.82,,,percent of total billed charges,,,,,,,,,437.4,,,percent of total billed charges,,,466.56,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.98,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO KNEE LT S ANDI,3225760,CDM,322,RC,73580,CPT,,,,,LT  ,outpatient,facility,,,486,204.12,131.22,466.56,,413.1,,,percent of total billed charges,,,131.22,,,percent of total billed charges,,,334.37,,,percent of total billed charges,,,327.08,,,percent of total billed charges,,,410.67,,,percent of total billed charges,,,,,,,,,422.82,,,percent of total billed charges,,,422.82,,,percent of total billed charges,,,413.1,,,percent of total billed charges,,,466.56,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,437.4,,,percent of total billed charges,,,,,,,,,451.98,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,379.57,,,percent of total billed charges,,,442.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO KNEE LT S ANDI,3225760,CDM,322,RC,73580,CPT,5572,APC,,,LT  ,outpatient,facility,,,486,486,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO KNEE RT S ANDI,3225778,CDM,322,RC,73580,CPT,,,,,RT  ,inpatient,facility,,,486,204.12,413.1,466.56,,413.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,422.82,,,percent of total billed charges,,,,,,,,,437.4,,,percent of total billed charges,,,466.56,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,451.98,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO KNEE RT S ANDI,3225778,CDM,322,RC,73580,CPT,,,,,RT  ,outpatient,facility,,,486,204.12,131.22,466.56,,413.1,,,percent of total billed charges,,,131.22,,,percent of total billed charges,,,334.37,,,percent of total billed charges,,,327.08,,,percent of total billed charges,,,410.67,,,percent of total billed charges,,,,,,,,,422.82,,,percent of total billed charges,,,422.82,,,percent of total billed charges,,,413.1,,,percent of total billed charges,,,466.56,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,437.4,,,percent of total billed charges,,,,,,,,,451.98,,,percent of total billed charges,,,461.7,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,379.57,,,percent of total billed charges,,,442.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO KNEE RT S ANDI,3225778,CDM,322,RC,73580,CPT,5572,APC,,,RT  ,outpatient,facility,,,486,486,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO WRIST LT S ANDI,3225802,CDM,322,RC,73115,CPT,,,,,LT  ,inpatient,facility,,,450,189,382.5,432,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO WRIST LT S ANDI,3225802,CDM,322,RC,73115,CPT,,,,,LT  ,outpatient,facility,,,450,189,121.5,432,,382.5,,,percent of total billed charges,,,121.5,,,percent of total billed charges,,,309.6,,,percent of total billed charges,,,302.85,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,,382.5,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,351.45,,,percent of total billed charges,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO WRIST LT S ANDI,3225802,CDM,322,RC,73115,CPT,5572,APC,,,LT  ,outpatient,facility,,,450,450,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ARTHRO WRIST RT S ANDI,3225810,CDM,322,RC,73115,CPT,,,,,RT  ,inpatient,facility,,,450,189,382.5,432,,382.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,391.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ARTHRO WRIST RT S ANDI,3225810,CDM,322,RC,73115,CPT,,,,,RT  ,outpatient,facility,,,450,189,121.5,432,,382.5,,,percent of total billed charges,,,121.5,,,percent of total billed charges,,,309.6,,,percent of total billed charges,,,302.85,,,percent of total billed charges,,,380.25,,,percent of total billed charges,,,,,,,,,391.5,,,percent of total billed charges,,,391.5,,,percent of total billed charges,,,382.5,,,percent of total billed charges,,,432,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,405,,,percent of total billed charges,,,,,,,,,418.5,,,percent of total billed charges,,,427.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,351.45,,,percent of total billed charges,,,409.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ARTHRO WRIST RT S ANDI,3225810,CDM,322,RC,73115,CPT,5572,APC,,,RT  ,outpatient,facility,,,450,450,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ARTHRO TMJ LT S ANDI,3225828,CDM,322,RC,70332,CPT,,,,,LT  ,inpatient,facility,,,254,106.68,215.9,243.84,,215.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.98,,,percent of total billed charges,,,,,,,,,228.6,,,percent of total billed charges,,,243.84,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,236.22,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ARTHRO TMJ LT S ANDI,3225828,CDM,322,RC,70332,CPT,,,,,LT  ,outpatient,facility,,,254,106.68,68.58,250.05,,215.9,,,percent of total billed charges,,,68.58,,,percent of total billed charges,,,174.75,,,percent of total billed charges,,,170.94,,,percent of total billed charges,,,214.63,,,percent of total billed charges,,,,,,,,,220.98,,,percent of total billed charges,,,220.98,,,percent of total billed charges,,,215.9,,,percent of total billed charges,,,243.84,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,228.6,,,percent of total billed charges,,,,,,,,,236.22,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,198.37,,,percent of total billed charges,,,231.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ARTHRO TMJ LT S ANDI,3225828,CDM,322,RC,70332,CPT,5523,APC,,,LT  ,outpatient,facility,,,254,254,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ARTHRO TMJ RT S ANDI,3225836,CDM,322,RC,70332,CPT,,,,,RT  ,inpatient,facility,,,254,106.68,215.9,243.84,,215.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.98,,,percent of total billed charges,,,,,,,,,228.6,,,percent of total billed charges,,,243.84,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,236.22,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ARTHRO TMJ RT S ANDI,3225836,CDM,322,RC,70332,CPT,,,,,RT  ,outpatient,facility,,,254,106.68,68.58,250.05,,215.9,,,percent of total billed charges,,,68.58,,,percent of total billed charges,,,174.75,,,percent of total billed charges,,,170.94,,,percent of total billed charges,,,214.63,,,percent of total billed charges,,,,,,,,,220.98,,,percent of total billed charges,,,220.98,,,percent of total billed charges,,,215.9,,,percent of total billed charges,,,243.84,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,228.6,,,percent of total billed charges,,,,,,,,,236.22,,,percent of total billed charges,,,241.3,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,198.37,,,percent of total billed charges,,,231.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ARTHRO TMJ RT S ANDI,3225836,CDM,322,RC,70332,CPT,5523,APC,,,RT  ,outpatient,facility,,,254,254,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO ADRENAL SEL LT S ANDI,3225844,CDM,323,RC,75731,CPT,,,,,LT  ,inpatient,facility,,,5845,2454.9,4968.25,5611.2,,4968.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.15,,,percent of total billed charges,,,,,,,,,5260.5,,,percent of total billed charges,,,5611.2,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5435.85,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO ADRENAL SEL LT S ANDI,3225844,CDM,323,RC,75731,CPT,,,,,LT  ,outpatient,facility,,,5845,2454.9,1578.15,5611.2,,4968.25,,,percent of total billed charges,,,1578.15,,,percent of total billed charges,,,4021.36,,,percent of total billed charges,,,3933.68,,,percent of total billed charges,,,4939.02,,,percent of total billed charges,,,,,,,,,5085.15,,,percent of total billed charges,,,5085.15,,,percent of total billed charges,,,4968.25,,,percent of total billed charges,,,5611.2,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,5260.5,,,percent of total billed charges,,,,,,,,,5435.85,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4564.94,,,percent of total billed charges,,,5318.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO ADRENAL SEL LT S ANDI,3225844,CDM,323,RC,75731,CPT,5183,APC,,,LT  ,outpatient,facility,,,5845,5845,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO ADRENAL SEL RT S ANDI,3225851,CDM,323,RC,75731,CPT,,,,,RT  ,inpatient,facility,,,5845,2454.9,4968.25,5611.2,,4968.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5085.15,,,percent of total billed charges,,,,,,,,,5260.5,,,percent of total billed charges,,,5611.2,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5435.85,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO ADRENAL SEL RT S ANDI,3225851,CDM,323,RC,75731,CPT,,,,,RT  ,outpatient,facility,,,5845,2454.9,1578.15,5611.2,,4968.25,,,percent of total billed charges,,,1578.15,,,percent of total billed charges,,,4021.36,,,percent of total billed charges,,,3933.68,,,percent of total billed charges,,,4939.02,,,percent of total billed charges,,,,,,,,,5085.15,,,percent of total billed charges,,,5085.15,,,percent of total billed charges,,,4968.25,,,percent of total billed charges,,,5611.2,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,5260.5,,,percent of total billed charges,,,,,,,,,5435.85,,,percent of total billed charges,,,5552.75,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4564.94,,,percent of total billed charges,,,5318.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO ADRENAL SEL RT S ANDI,3225851,CDM,323,RC,75731,CPT,5183,APC,,,RT  ,outpatient,facility,,,5845,5845,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO ADRENAL SEL BI S ANDI,3225869,CDM,323,RC,75733,CPT,,,,,,inpatient,facility,,,8768,3682.56,7452.8,8417.28,,7452.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7628.16,,,percent of total billed charges,,,,,,,,,7891.2,,,percent of total billed charges,,,8417.28,,,percent of total billed charges,,,8329.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8154.24,,,percent of total billed charges,,,8329.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO ADRENAL SEL BI S ANDI,3225869,CDM,323,RC,75733,CPT,,,,,,outpatient,facility,,,8768,3682.56,2367.36,8417.28,,7452.8,,,percent of total billed charges,,,2367.36,,,percent of total billed charges,,,6032.38,,,percent of total billed charges,,,5900.86,,,percent of total billed charges,,,7408.96,,,percent of total billed charges,,,,,,,,,7628.16,,,percent of total billed charges,,,7628.16,,,percent of total billed charges,,,7452.8,,,percent of total billed charges,,,8417.28,,,percent of total billed charges,,,8329.6,,,percent of total billed charges,,,,,,,,,7891.2,,,percent of total billed charges,,,,,,,,,8154.24,,,percent of total billed charges,,,8329.6,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,6847.81,,,percent of total billed charges,,,7978.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO ADRENAL SEL BI S ANDI,3225869,CDM,323,RC,75733,CPT,5183,APC,,,,outpatient,facility,,,8768,8768,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO EXTREMITY BI S ANDI,3225992,CDM,323,RC,75716,CPT,,,,,,inpatient,facility,,,11899,4997.58,10114.15,11423.04,,10114.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10352.13,,,percent of total billed charges,,,,,,,,,10709.1,,,percent of total billed charges,,,11423.04,,,percent of total billed charges,,,11304.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11066.07,,,percent of total billed charges,,,11304.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO EXTREMITY BI S ANDI,3225992,CDM,323,RC,75716,CPT,,,,,,outpatient,facility,,,11899,4997.58,3187.59,11423.04,,10114.15,,,percent of total billed charges,,,3212.73,,,percent of total billed charges,,,8186.51,,,percent of total billed charges,,,8008.03,,,percent of total billed charges,,,10054.65,,,percent of total billed charges,,,,,,,,,10352.13,,,percent of total billed charges,,,10352.13,,,percent of total billed charges,,,10114.15,,,percent of total billed charges,,,11423.04,,,percent of total billed charges,,,11304.05,,,percent of total billed charges,,,,,,,,,10709.1,,,percent of total billed charges,,,,,,,,,11066.07,,,percent of total billed charges,,,11304.05,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,9293.12,,,percent of total billed charges,,,10828.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO EXTREMITY BI S ANDI,3225992,CDM,323,RC,75716,CPT,5183,APC,,,,outpatient,facility,,,11899,11899,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO EXTREMITY LT S ANDI,3226008,CDM,323,RC,75710,CPT,,,,,LT  ,inpatient,facility,,,7457,3131.94,6338.45,7158.72,,6338.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6487.59,,,percent of total billed charges,,,,,,,,,6711.3,,,percent of total billed charges,,,7158.72,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6935.01,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO EXTREMITY LT S ANDI,3226008,CDM,323,RC,75710,CPT,,,,,LT  ,outpatient,facility,,,7457,3131.94,2013.39,7158.72,,6338.45,,,percent of total billed charges,,,2013.39,,,percent of total billed charges,,,5130.42,,,percent of total billed charges,,,5018.56,,,percent of total billed charges,,,6301.16,,,percent of total billed charges,,,,,,,,,6487.59,,,percent of total billed charges,,,6487.59,,,percent of total billed charges,,,6338.45,,,percent of total billed charges,,,7158.72,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,6711.3,,,percent of total billed charges,,,,,,,,,6935.01,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,5823.92,,,percent of total billed charges,,,6785.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO EXTREMITY LT S ANDI,3226008,CDM,323,RC,75710,CPT,5183,APC,,,LT  ,outpatient,facility,,,7457,7457,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO EXTREMITY RT S ANDI,3226016,CDM,323,RC,75710,CPT,,,,,RT  ,inpatient,facility,,,7457,3131.94,6338.45,7158.72,,6338.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6487.59,,,percent of total billed charges,,,,,,,,,6711.3,,,percent of total billed charges,,,7158.72,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6935.01,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO EXTREMITY RT S ANDI,3226016,CDM,323,RC,75710,CPT,,,,,RT  ,outpatient,facility,,,7457,3131.94,2013.39,7158.72,,6338.45,,,percent of total billed charges,,,2013.39,,,percent of total billed charges,,,5130.42,,,percent of total billed charges,,,5018.56,,,percent of total billed charges,,,6301.16,,,percent of total billed charges,,,,,,,,,6487.59,,,percent of total billed charges,,,6487.59,,,percent of total billed charges,,,6338.45,,,percent of total billed charges,,,7158.72,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,6711.3,,,percent of total billed charges,,,,,,,,,6935.01,,,percent of total billed charges,,,7084.15,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,5823.92,,,percent of total billed charges,,,6785.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO EXTREMITY RT S ANDI,3226016,CDM,323,RC,75710,CPT,5183,APC,,,RT  ,outpatient,facility,,,7457,7457,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO MAMMARY INTERNAL S ANDI,3226024,CDM,323,RC,75756,CPT,,,,,,inpatient,facility,,,3121,1310.82,2652.85,2996.16,,2652.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2715.27,,,percent of total billed charges,,,,,,,,,2808.9,,,percent of total billed charges,,,2996.16,,,percent of total billed charges,,,2964.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2902.53,,,percent of total billed charges,,,2964.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO MAMMARY INTERNAL S ANDI,3226024,CDM,323,RC,75756,CPT,,,,,,outpatient,facility,,,3121,1310.82,842.67,3252.64,,2652.85,,,percent of total billed charges,,,842.67,,,percent of total billed charges,,,2147.25,,,percent of total billed charges,,,2100.43,,,percent of total billed charges,,,2637.24,,,percent of total billed charges,,,,,,,,,2715.27,,,percent of total billed charges,,,2715.27,,,percent of total billed charges,,,2652.85,,,percent of total billed charges,,,2996.16,,,percent of total billed charges,,,2964.95,,,percent of total billed charges,,,,,,,,,2808.9,,,percent of total billed charges,,,,,,,,,2902.53,,,percent of total billed charges,,,2964.95,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,2437.5,,,percent of total billed charges,,,2840.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO MAMMARY INTERNAL S ANDI,3226024,CDM,323,RC,75756,CPT,5183,APC,,,,outpatient,facility,,,3121,3121,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO PULMONARY NONSEL S ANDI,3226057,CDM,323,RC,75746,CPT,,,,,,inpatient,facility,,,8110,3406.2,6893.5,7785.6,,6893.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7055.7,,,percent of total billed charges,,,,,,,,,7299,,,percent of total billed charges,,,7785.6,,,percent of total billed charges,,,7704.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7542.3,,,percent of total billed charges,,,7704.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY NONSEL S ANDI,3226057,CDM,323,RC,75746,CPT,,,,,,outpatient,facility,,,8110,3406.2,2189.7,8110,,6893.5,,,percent of total billed charges,,,2189.7,,,percent of total billed charges,,,5579.68,,,percent of total billed charges,,,5458.03,,,percent of total billed charges,,,6852.95,,,percent of total billed charges,,,,,,,,,7055.7,,,percent of total billed charges,,,7055.7,,,percent of total billed charges,,,6893.5,,,percent of total billed charges,,,7785.6,,,percent of total billed charges,,,7704.5,,,percent of total billed charges,,,,,,,,,7299,,,percent of total billed charges,,,,,,,,,7542.3,,,percent of total billed charges,,,7704.5,,,percent of total billed charges,,,,,,,,,,,,,,,8110,,,fee schedule,,,8110,,,fee schedule,,,8110,,,fee schedule,,,,,,,,,6333.91,,,percent of total billed charges,,,7380.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY NONSEL S ANDI,3226057,CDM,323,RC,75746,CPT,5183,APC,,,,outpatient,facility,,,8110,8110,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO PULMONARY SEL BI S ANDI,3226065,CDM,323,RC,75743,CPT,,,,,,inpatient,facility,,,13517,5677.14,11489.45,12976.32,,11489.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11759.79,,,percent of total billed charges,,,,,,,,,12165.3,,,percent of total billed charges,,,12976.32,,,percent of total billed charges,,,12841.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12570.81,,,percent of total billed charges,,,12841.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY SEL BI S ANDI,3226065,CDM,323,RC,75743,CPT,,,,,,outpatient,facility,,,13517,5677.14,3187.59,12976.32,,11489.45,,,percent of total billed charges,,,3649.59,,,percent of total billed charges,,,9299.7,,,percent of total billed charges,,,9096.94,,,percent of total billed charges,,,11421.86,,,percent of total billed charges,,,,,,,,,11759.79,,,percent of total billed charges,,,11759.79,,,percent of total billed charges,,,11489.45,,,percent of total billed charges,,,12976.32,,,percent of total billed charges,,,12841.15,,,percent of total billed charges,,,,,,,,,12165.3,,,percent of total billed charges,,,,,,,,,12570.81,,,percent of total billed charges,,,12841.15,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,10556.78,,,percent of total billed charges,,,12300.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY SEL BI S ANDI,3226065,CDM,323,RC,75743,CPT,5183,APC,,,,outpatient,facility,,,13517,13517,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO PULMONARY SEL LT S ANDI,3226073,CDM,323,RC,75741,CPT,,,,,LT  ,inpatient,facility,,,8020,3368.4,6817,7699.2,,6817,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6977.4,,,percent of total billed charges,,,,,,,,,7218,,,percent of total billed charges,,,7699.2,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7458.6,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY SEL LT S ANDI,3226073,CDM,323,RC,75741,CPT,,,,,LT  ,outpatient,facility,,,8020,3368.4,2165.4,7699.2,,6817,,,percent of total billed charges,,,2165.4,,,percent of total billed charges,,,5517.76,,,percent of total billed charges,,,5397.46,,,percent of total billed charges,,,6776.9,,,percent of total billed charges,,,,,,,,,6977.4,,,percent of total billed charges,,,6977.4,,,percent of total billed charges,,,6817,,,percent of total billed charges,,,7699.2,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,7218,,,percent of total billed charges,,,,,,,,,7458.6,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,6263.62,,,percent of total billed charges,,,7298.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY SEL LT S ANDI,3226073,CDM,323,RC,75741,CPT,5183,APC,,,LT  ,outpatient,facility,,,8020,8020,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO PULMONARY SEL RT S ANDI,3226081,CDM,323,RC,75741,CPT,,,,,RT  ,inpatient,facility,,,8020,3368.4,6817,7699.2,,6817,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6977.4,,,percent of total billed charges,,,,,,,,,7218,,,percent of total billed charges,,,7699.2,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7458.6,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY SEL RT S ANDI,3226081,CDM,323,RC,75741,CPT,,,,,RT  ,outpatient,facility,,,8020,3368.4,2165.4,7699.2,,6817,,,percent of total billed charges,,,2165.4,,,percent of total billed charges,,,5517.76,,,percent of total billed charges,,,5397.46,,,percent of total billed charges,,,6776.9,,,percent of total billed charges,,,,,,,,,6977.4,,,percent of total billed charges,,,6977.4,,,percent of total billed charges,,,6817,,,percent of total billed charges,,,7699.2,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,7218,,,percent of total billed charges,,,,,,,,,7458.6,,,percent of total billed charges,,,7619,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,6263.62,,,percent of total billed charges,,,7298.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO PULMONARY SEL RT S ANDI,3226081,CDM,323,RC,75741,CPT,5183,APC,,,RT  ,outpatient,facility,,,8020,8020,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO SEL VESSEL ADDL S ANDI,3226123,CDM,323,RC,75774,CPT,,,,,,inpatient,facility,,,2580,1083.6,2193,2476.8,,2193,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2244.6,,,percent of total billed charges,,,,,,,,,2322,,,percent of total billed charges,,,2476.8,,,percent of total billed charges,,,2451,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2399.4,,,percent of total billed charges,,,2451,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO SEL VESSEL ADDL S ANDI,3226123,CDM,323,RC,75774,CPT,,,,,,outpatient,facility,,,2580,1083.6,696.6,2580,,2193,,,percent of total billed charges,,,696.6,,,percent of total billed charges,,,1775.04,,,percent of total billed charges,,,1736.34,,,percent of total billed charges,,,2180.1,,,percent of total billed charges,,,,,,,,,2244.6,,,percent of total billed charges,,,2244.6,,,percent of total billed charges,,,2193,,,percent of total billed charges,,,2476.8,,,percent of total billed charges,,,2451,,,percent of total billed charges,,,,,,,,,2322,,,percent of total billed charges,,,,,,,,,2399.4,,,percent of total billed charges,,,2451,,,percent of total billed charges,,,,,,,,,,,,,,,2580,,,fee schedule,,,2580,,,fee schedule,,,2580,,,fee schedule,,,,,,,,,2014.98,,,percent of total billed charges,,,2347.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO VISCERAL SEL S ANDI,3226156,CDM,323,RC,75726,CPT,,,,,,inpatient,facility,,,6101,2562.42,5185.85,5856.96,,5185.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5307.87,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO VISCERAL SEL S ANDI,3226156,CDM,323,RC,75726,CPT,,,,,,outpatient,facility,,,6101,2562.42,1647.27,5856.96,,5185.85,,,percent of total billed charges,,,1647.27,,,percent of total billed charges,,,4197.49,,,percent of total billed charges,,,4105.97,,,percent of total billed charges,,,5155.35,,,percent of total billed charges,,,,,,,,,5307.87,,,percent of total billed charges,,,5307.87,,,percent of total billed charges,,,5185.85,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,4764.88,,,percent of total billed charges,,,5551.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO VISCERAL SEL S ANDI,3226156,CDM,323,RC,75726,CPT,5184,APC,,,,outpatient,facility,,,6101,6101,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
AORTO ABD SERIAL S ANDI,3226164,CDM,323,RC,75625,CPT,,,,,,inpatient,facility,,,6101,2562.42,5185.85,5856.96,,5185.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5307.87,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
AORTO ABD SERIAL S ANDI,3226164,CDM,323,RC,75625,CPT,,,,,,outpatient,facility,,,6101,2562.42,1647.27,5856.96,,5185.85,,,percent of total billed charges,,,1647.27,,,percent of total billed charges,,,4197.49,,,percent of total billed charges,,,4105.97,,,percent of total billed charges,,,5155.35,,,percent of total billed charges,,,,,,,,,5307.87,,,percent of total billed charges,,,5307.87,,,percent of total billed charges,,,5185.85,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,4764.88,,,percent of total billed charges,,,5551.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
AORTO ABD SERIAL S ANDI,3226164,CDM,323,RC,75625,CPT,5183,APC,,,,outpatient,facility,,,6101,6101,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
AORTO ABD ILIOFEM BI SERIAL S ANDI,3226172,CDM,323,RC,75630,CPT,,,,,,inpatient,facility,,,11439,4804.38,9723.15,10981.44,,9723.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9951.93,,,percent of total billed charges,,,,,,,,,10295.1,,,percent of total billed charges,,,10981.44,,,percent of total billed charges,,,10867.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,10638.27,,,percent of total billed charges,,,10867.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
AORTO ABD ILIOFEM BI SERIAL S ANDI,3226172,CDM,323,RC,75630,CPT,,,,,,outpatient,facility,,,11439,4804.38,3088.53,10981.44,,9723.15,,,percent of total billed charges,,,3088.53,,,percent of total billed charges,,,7870.03,,,percent of total billed charges,,,7698.45,,,percent of total billed charges,,,9665.95,,,percent of total billed charges,,,,,,,,,9951.93,,,percent of total billed charges,,,9951.93,,,percent of total billed charges,,,9723.15,,,percent of total billed charges,,,10981.44,,,percent of total billed charges,,,10867.05,,,percent of total billed charges,,,,,,,,,10295.1,,,percent of total billed charges,,,,,,,,,10638.27,,,percent of total billed charges,,,10867.05,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,8933.86,,,percent of total billed charges,,,10409.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
AORTO ABD ILIOFEM BI SERIAL S ANDI,3226172,CDM,323,RC,75630,CPT,5183,APC,,,,outpatient,facility,,,11439,11439,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
AORTO THORACIC SERIAL S ANDI,3226180,CDM,323,RC,75605,CPT,,,,,,inpatient,facility,,,6101,2562.42,5185.85,5856.96,,5185.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5307.87,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
AORTO THORACIC SERIAL S ANDI,3226180,CDM,323,RC,75605,CPT,,,,,,outpatient,facility,,,6101,2562.42,1647.27,5856.96,,5185.85,,,percent of total billed charges,,,1647.27,,,percent of total billed charges,,,4197.49,,,percent of total billed charges,,,4105.97,,,percent of total billed charges,,,5155.35,,,percent of total billed charges,,,,,,,,,5307.87,,,percent of total billed charges,,,5307.87,,,percent of total billed charges,,,5185.85,,,percent of total billed charges,,,5856.96,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,5490.9,,,percent of total billed charges,,,,,,,,,5673.93,,,percent of total billed charges,,,5795.95,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,4764.88,,,percent of total billed charges,,,5551.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
AORTO THORACIC SERIAL S ANDI,3226180,CDM,323,RC,75605,CPT,5184,APC,,,,outpatient,facility,,,6101,6101,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
AORTO THORACIC WO SERIAL S ANDI,3226198,CDM,323,RC,75600,CPT,,,,,,inpatient,facility,,,9456,3971.52,8037.6,9077.76,,8037.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8226.72,,,percent of total billed charges,,,,,,,,,8510.4,,,percent of total billed charges,,,9077.76,,,percent of total billed charges,,,8983.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8794.08,,,percent of total billed charges,,,8983.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
AORTO THORACIC WO SERIAL S ANDI,3226198,CDM,323,RC,75600,CPT,,,,,,outpatient,facility,,,9456,3971.52,2553.12,9077.76,,8037.6,,,percent of total billed charges,,,2553.12,,,percent of total billed charges,,,6505.73,,,percent of total billed charges,,,6363.89,,,percent of total billed charges,,,7990.32,,,percent of total billed charges,,,,,,,,,8226.72,,,percent of total billed charges,,,8226.72,,,percent of total billed charges,,,8037.6,,,percent of total billed charges,,,9077.76,,,percent of total billed charges,,,8983.2,,,percent of total billed charges,,,,,,,,,8510.4,,,percent of total billed charges,,,,,,,,,8794.08,,,percent of total billed charges,,,8983.2,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,7385.14,,,percent of total billed charges,,,8604.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
AORTO THORACIC WO SERIAL S ANDI,3226198,CDM,323,RC,75600,CPT,5183,APC,,,,outpatient,facility,,,9456,9456,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TOE S 2 PLUS VW LT,3226479,CDM,320,RC,73660,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TOE S 2 PLUS VW LT,3226479,CDM,320,RC,73660,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TOE S 2 PLUS VW LT,3226479,CDM,320,RC,73660,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TOE S 2 PLUS VW RT,3226487,CDM,320,RC,73660,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TOE S 2 PLUS VW RT,3226487,CDM,320,RC,73660,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TOE S 2 PLUS VW RT,3226487,CDM,320,RC,73660,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REPOS G TUBE NASO ORO,3228004,CDM,361,RC,43761,CPT,,,,,,inpatient,facility,,,1783,748.86,1515.55,1711.68,,1515.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.21,,,percent of total billed charges,,,,,,,,,1604.7,,,percent of total billed charges,,,1711.68,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1658.19,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REPOS G TUBE NASO ORO,3228004,CDM,361,RC,43761,CPT,,,,,,outpatient,facility,,,1783,748.86,247.16,3428,,1515.55,,,percent of total billed charges,,,481.41,,,percent of total billed charges,,,1226.7,,,percent of total billed charges,,,1199.96,,,percent of total billed charges,,,1506.63,,,percent of total billed charges,,,,,,,,,1551.21,,,percent of total billed charges,,,1551.21,,,percent of total billed charges,,,1515.55,,,percent of total billed charges,,,1711.68,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,1604.7,,,percent of total billed charges,,,,,,,,,1658.19,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,,,,,,,252.2,,,fee schedule,,,252.2,,,fee schedule,,,247.16,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1622.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REPOS G TUBE NASO ORO,3228004,CDM,361,RC,43761,CPT,5371,APC,,,,outpatient,facility,,,1783,1783,116.72,365.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,252.2,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,257.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,252.2,,,fee schedule,,,,,,,,,,,,,,,365.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",340.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,252.2,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,252.2,,,fee schedule,,,252.2,,,fee schedule,,,116.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PUNCT SPINE THER DRN CSF,3228194,CDM,361,RC,62272,CPT,,,,,,inpatient,facility,,,845,354.9,718.25,811.2,,718.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,735.15,,,percent of total billed charges,,,,,,,,,760.5,,,percent of total billed charges,,,811.2,,,percent of total billed charges,,,802.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,785.85,,,percent of total billed charges,,,802.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCT SPINE THER DRN CSF,3228194,CDM,361,RC,62272,CPT,,,,,,outpatient,facility,,,845,354.9,228.15,3522,,718.25,,,percent of total billed charges,,,228.15,,,percent of total billed charges,,,581.36,,,percent of total billed charges,,,568.68,,,percent of total billed charges,,,714.02,,,percent of total billed charges,,,,,,,,,735.15,,,percent of total billed charges,,,735.15,,,percent of total billed charges,,,718.25,,,percent of total billed charges,,,811.2,,,percent of total billed charges,,,802.75,,,percent of total billed charges,,,,,,,,,760.5,,,percent of total billed charges,,,,,,,,,785.85,,,percent of total billed charges,,,802.75,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,768.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCT SPINE THER DRN CSF,3228194,CDM,361,RC,62272,CPT,5442,APC,,,,outpatient,facility,,,845,845,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO CNS REQ PUNCTURE SPINAL,3228459,CDM,331,RC,96450,CPT,,,,,,inpatient,facility,,,2830,1188.6,2405.5,2716.8,,2405.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2462.1,,,percent of total billed charges,,,,,,,,,2547,,,percent of total billed charges,,,2716.8,,,percent of total billed charges,,,2688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2631.9,,,percent of total billed charges,,,2688.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO CNS REQ PUNCTURE SPINAL,3228459,CDM,331,RC,96450,CPT,,,,,,outpatient,facility,,,2830,1188.6,338.68,2716.8,,2405.5,,,percent of total billed charges,,,764.1,,,percent of total billed charges,,,1947.04,,,percent of total billed charges,,,1904.59,,,percent of total billed charges,,,2391.35,,,percent of total billed charges,,,,,,,,,2462.1,,,percent of total billed charges,,,2462.1,,,percent of total billed charges,,,2405.5,,,percent of total billed charges,,,2716.8,,,percent of total billed charges,,,2688.5,,,percent of total billed charges,,,,,,,,,2547,,,percent of total billed charges,,,,,,,,,2631.9,,,percent of total billed charges,,,2688.5,,,percent of total billed charges,,,,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,338.68,,,fee schedule,,,,,,,,,2210.23,,,percent of total billed charges,,,2575.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO CNS REQ PUNCTURE SPINAL,3228459,CDM,331,RC,96450,CPT,5694,APC,,,,outpatient,facility,,,2830,2830,180.68,501.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,501.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",466.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,345.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,180.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ ARTHRO HIP WO ANES LT,3228467,CDM,361,RC,27093,CPT,,,,,LT  ,inpatient,facility,,,505,212.1,429.25,484.8,,429.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.35,,,percent of total billed charges,,,,,,,,,454.5,,,percent of total billed charges,,,484.8,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,469.65,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO HIP WO ANES LT,3228467,CDM,361,RC,27093,CPT,,,,,LT  ,outpatient,facility,,,505,212.1,136.35,3428,,429.25,,,percent of total billed charges,,,136.35,,,percent of total billed charges,,,347.44,,,percent of total billed charges,,,339.86,,,percent of total billed charges,,,426.72,,,percent of total billed charges,,,,,,,,,439.35,,,percent of total billed charges,,,439.35,,,percent of total billed charges,,,429.25,,,percent of total billed charges,,,484.8,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,,469.65,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,,,,,,,505,,,fee schedule,,,505,,,fee schedule,,,505,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,459.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO HIP WO ANES RT,3228475,CDM,361,RC,27093,CPT,,,,,RT  ,inpatient,facility,,,505,212.1,429.25,484.8,,429.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,439.35,,,percent of total billed charges,,,,,,,,,454.5,,,percent of total billed charges,,,484.8,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,469.65,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO HIP WO ANES RT,3228475,CDM,361,RC,27093,CPT,,,,,RT  ,outpatient,facility,,,505,212.1,136.35,3428,,429.25,,,percent of total billed charges,,,136.35,,,percent of total billed charges,,,347.44,,,percent of total billed charges,,,339.86,,,percent of total billed charges,,,426.72,,,percent of total billed charges,,,,,,,,,439.35,,,percent of total billed charges,,,439.35,,,percent of total billed charges,,,429.25,,,percent of total billed charges,,,484.8,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,454.5,,,percent of total billed charges,,,,,,,,,469.65,,,percent of total billed charges,,,479.75,,,percent of total billed charges,,,,,,,,,,,,,,,505,,,fee schedule,,,505,,,fee schedule,,,505,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,459.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTILL AGENT PLEURODESIS W TB CATH,3228541,CDM,361,RC,32560,CPT,,,,,,inpatient,facility,,,1501,630.42,1275.85,1440.96,,1275.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1305.87,,,percent of total billed charges,,,,,,,,,1350.9,,,percent of total billed charges,,,1440.96,,,percent of total billed charges,,,1425.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1395.93,,,percent of total billed charges,,,1425.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTILL AGENT PLEURODESIS W TB CATH,3228541,CDM,361,RC,32560,CPT,,,,,,outpatient,facility,,,1501,630.42,405.27,3522,,1275.85,,,percent of total billed charges,,,405.27,,,percent of total billed charges,,,1032.69,,,percent of total billed charges,,,1010.17,,,percent of total billed charges,,,1268.35,,,percent of total billed charges,,,,,,,,,1305.87,,,percent of total billed charges,,,1305.87,,,percent of total billed charges,,,1275.85,,,percent of total billed charges,,,1440.96,,,percent of total billed charges,,,1425.95,,,percent of total billed charges,,,,,,,,,1350.9,,,percent of total billed charges,,,,,,,,,1395.93,,,percent of total billed charges,,,1425.95,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1365.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTILL AGENT PLEURODESIS W TB CATH,3228541,CDM,361,RC,32560,CPT,5181,APC,,,,outpatient,facility,,,1501,1501,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ VENOGRAPHY EXTREMITY BI,3228558,CDM,361,RC,36005,CPT,,,,,50,inpatient,facility,,,1554,652.68,1320.9,1491.84,,1320.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1351.98,,,percent of total billed charges,,,,,,,,,1398.6,,,percent of total billed charges,,,1491.84,,,percent of total billed charges,,,1476.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1445.22,,,percent of total billed charges,,,1476.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ VENOGRAPHY EXTREMITY BI,3228558,CDM,361,RC,36005,CPT,,,,,50,outpatient,facility,,,1554,652.68,419.58,3428,,1320.9,,,percent of total billed charges,,,419.58,,,percent of total billed charges,,,1069.15,,,percent of total billed charges,,,1045.84,,,percent of total billed charges,,,1313.13,,,percent of total billed charges,,,,,,,,,1351.98,,,percent of total billed charges,,,1351.98,,,percent of total billed charges,,,1320.9,,,percent of total billed charges,,,1491.84,,,percent of total billed charges,,,1476.3,,,percent of total billed charges,,,,,,,,,1398.6,,,percent of total billed charges,,,,,,,,,1445.22,,,percent of total billed charges,,,1476.3,,,percent of total billed charges,,,,,,,,,,,,,,,1554,,,fee schedule,,,1554,,,fee schedule,,,1554,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1414.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ VENOGRAPHY EXTREMITY LT,3228566,CDM,361,RC,36005,CPT,,,,,LT  ,inpatient,facility,,,1036,435.12,880.6,994.56,,880.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,901.32,,,percent of total billed charges,,,,,,,,,932.4,,,percent of total billed charges,,,994.56,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,963.48,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ VENOGRAPHY EXTREMITY LT,3228566,CDM,361,RC,36005,CPT,,,,,LT  ,outpatient,facility,,,1036,435.12,279.72,3428,,880.6,,,percent of total billed charges,,,279.72,,,percent of total billed charges,,,712.77,,,percent of total billed charges,,,697.23,,,percent of total billed charges,,,875.42,,,percent of total billed charges,,,,,,,,,901.32,,,percent of total billed charges,,,901.32,,,percent of total billed charges,,,880.6,,,percent of total billed charges,,,994.56,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,932.4,,,percent of total billed charges,,,,,,,,,963.48,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,1036,,,fee schedule,,,1036,,,fee schedule,,,1036,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,942.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ VENOGRAPHY EXTREMITY RT,3228574,CDM,361,RC,36005,CPT,,,,,RT  ,inpatient,facility,,,1036,435.12,880.6,994.56,,880.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,901.32,,,percent of total billed charges,,,,,,,,,932.4,,,percent of total billed charges,,,994.56,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,963.48,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ VENOGRAPHY EXTREMITY RT,3228574,CDM,361,RC,36005,CPT,,,,,RT  ,outpatient,facility,,,1036,435.12,279.72,3428,,880.6,,,percent of total billed charges,,,279.72,,,percent of total billed charges,,,712.77,,,percent of total billed charges,,,697.23,,,percent of total billed charges,,,875.42,,,percent of total billed charges,,,,,,,,,901.32,,,percent of total billed charges,,,901.32,,,percent of total billed charges,,,880.6,,,percent of total billed charges,,,994.56,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,932.4,,,percent of total billed charges,,,,,,,,,963.48,,,percent of total billed charges,,,984.2,,,percent of total billed charges,,,,,,,,,,,,,,,1036,,,fee schedule,,,1036,,,fee schedule,,,1036,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,942.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
UROGRAPHY ANTEGRADE S ANDI,3228756,CDM,320,RC,74425,CPT,,,,,,inpatient,facility,,,530,222.6,450.5,508.8,,450.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,461.1,,,percent of total billed charges,,,,,,,,,477,,,percent of total billed charges,,,508.8,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,492.9,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
UROGRAPHY ANTEGRADE S ANDI,3228756,CDM,320,RC,74425,CPT,,,,,,outpatient,facility,,,530,222.6,143.1,508.8,,450.5,,,percent of total billed charges,,,143.1,,,percent of total billed charges,,,364.64,,,percent of total billed charges,,,356.69,,,percent of total billed charges,,,447.85,,,percent of total billed charges,,,,,,,,,461.1,,,percent of total billed charges,,,461.1,,,percent of total billed charges,,,450.5,,,percent of total billed charges,,,508.8,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,477,,,percent of total billed charges,,,,,,,,,492.9,,,percent of total billed charges,,,503.5,,,percent of total billed charges,,,,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,384.59,,,fee schedule,,,,,,,,,413.93,,,percent of total billed charges,,,482.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
UROGRAPHY ANTEGRADE S ANDI,3228756,CDM,320,RC,74425,CPT,5572,APC,,,,outpatient,facility,,,530,530,200.13,569.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,400.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,392.44,,,fee schedule,,,,,,,,,,,,,,,569.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",529.79,,,fee schedule,,,,,,,,,,,,,,,,,,,,,392.44,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,392.44,,,fee schedule,,,392.44,,,fee schedule,,,200.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM EXTREMITY LT S ANDI,3228814,CDM,320,RC,75820,CPT,,,,,LT  ,inpatient,facility,,,2098,881.16,1783.3,2014.08,,1783.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1825.26,,,percent of total billed charges,,,,,,,,,1888.2,,,percent of total billed charges,,,2014.08,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1951.14,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM EXTREMITY LT S ANDI,3228814,CDM,320,RC,75820,CPT,,,,,LT  ,outpatient,facility,,,2098,881.16,566.46,2014.08,,1783.3,,,percent of total billed charges,,,566.46,,,percent of total billed charges,,,1443.42,,,percent of total billed charges,,,1411.95,,,percent of total billed charges,,,1772.81,,,percent of total billed charges,,,,,,,,,1825.26,,,percent of total billed charges,,,1825.26,,,percent of total billed charges,,,1783.3,,,percent of total billed charges,,,2014.08,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,1888.2,,,percent of total billed charges,,,,,,,,,1951.14,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,1638.54,,,percent of total billed charges,,,1909.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM EXTREMITY LT S ANDI,3228814,CDM,320,RC,75820,CPT,5182,APC,,,LT  ,outpatient,facility,,,2098,2098,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM EXTREMITY RT S ANDI,3228822,CDM,320,RC,75820,CPT,,,,,RT  ,inpatient,facility,,,2098,881.16,1783.3,2014.08,,1783.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1825.26,,,percent of total billed charges,,,,,,,,,1888.2,,,percent of total billed charges,,,2014.08,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1951.14,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM EXTREMITY RT S ANDI,3228822,CDM,320,RC,75820,CPT,,,,,RT  ,outpatient,facility,,,2098,881.16,566.46,2014.08,,1783.3,,,percent of total billed charges,,,566.46,,,percent of total billed charges,,,1443.42,,,percent of total billed charges,,,1411.95,,,percent of total billed charges,,,1772.81,,,percent of total billed charges,,,,,,,,,1825.26,,,percent of total billed charges,,,1825.26,,,percent of total billed charges,,,1783.3,,,percent of total billed charges,,,2014.08,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,1888.2,,,percent of total billed charges,,,,,,,,,1951.14,,,percent of total billed charges,,,1993.1,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,1638.54,,,percent of total billed charges,,,1909.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM EXTREMITY RT S ANDI,3228822,CDM,320,RC,75820,CPT,5182,APC,,,RT  ,outpatient,facility,,,2098,2098,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM EXTREMITY BI S ANDI,3228830,CDM,320,RC,75822,CPT,,,,,,inpatient,facility,,,3681,1546.02,3128.85,3533.76,,3128.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3202.47,,,percent of total billed charges,,,,,,,,,3312.9,,,percent of total billed charges,,,3533.76,,,percent of total billed charges,,,3496.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3423.33,,,percent of total billed charges,,,3496.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM EXTREMITY BI S ANDI,3228830,CDM,320,RC,75822,CPT,,,,,,outpatient,facility,,,3681,1546.02,993.87,3533.76,,3128.85,,,percent of total billed charges,,,993.87,,,percent of total billed charges,,,2532.53,,,percent of total billed charges,,,2477.31,,,percent of total billed charges,,,3110.44,,,percent of total billed charges,,,,,,,,,3202.47,,,percent of total billed charges,,,3202.47,,,percent of total billed charges,,,3128.85,,,percent of total billed charges,,,3533.76,,,percent of total billed charges,,,3496.95,,,percent of total billed charges,,,,,,,,,3312.9,,,percent of total billed charges,,,,,,,,,3423.33,,,percent of total billed charges,,,3496.95,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,2874.86,,,percent of total billed charges,,,3349.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM EXTREMITY BI S ANDI,3228830,CDM,320,RC,75822,CPT,5182,APC,,,,outpatient,facility,,,3681,3681,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VENOGRAM SVC SERIAL S ANDI,3228848,CDM,320,RC,75827,CPT,,,,,,inpatient,facility,,,1404,589.68,1193.4,1347.84,,1193.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1221.48,,,percent of total billed charges,,,,,,,,,1263.6,,,percent of total billed charges,,,1347.84,,,percent of total billed charges,,,1333.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1305.72,,,percent of total billed charges,,,1333.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VENOGRAM SVC SERIAL S ANDI,3228848,CDM,320,RC,75827,CPT,,,,,,outpatient,facility,,,1404,589.68,379.08,1634.27,,1193.4,,,percent of total billed charges,,,379.08,,,percent of total billed charges,,,965.95,,,percent of total billed charges,,,944.89,,,percent of total billed charges,,,1186.38,,,percent of total billed charges,,,,,,,,,1221.48,,,percent of total billed charges,,,1221.48,,,percent of total billed charges,,,1193.4,,,percent of total billed charges,,,1347.84,,,percent of total billed charges,,,1333.8,,,percent of total billed charges,,,,,,,,,1263.6,,,percent of total billed charges,,,,,,,,,1305.72,,,percent of total billed charges,,,1333.8,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,1096.52,,,percent of total billed charges,,,1277.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VENOGRAM SVC SERIAL S ANDI,3228848,CDM,320,RC,75827,CPT,5182,APC,,,,outpatient,facility,,,1404,1404,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
FLUORO 0 1HR TIME PHYS QHCP,3228913,CDM,320,RC,76000,CPT,,,,,,inpatient,facility,,,553,232.26,470.05,530.88,,470.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,481.11,,,percent of total billed charges,,,,,,,,,497.7,,,percent of total billed charges,,,530.88,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,514.29,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FLUORO 0 1HR TIME PHYS QHCP,3228913,CDM,320,RC,76000,CPT,,,,,,outpatient,facility,,,553,232.26,149.31,530.88,,470.05,,,percent of total billed charges,,,149.31,,,percent of total billed charges,,,380.46,,,percent of total billed charges,,,372.17,,,percent of total billed charges,,,467.28,,,percent of total billed charges,,,,,,,,,481.11,,,percent of total billed charges,,,481.11,,,percent of total billed charges,,,470.05,,,percent of total billed charges,,,530.88,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,497.7,,,percent of total billed charges,,,,,,,,,514.29,,,percent of total billed charges,,,525.35,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,431.89,,,percent of total billed charges,,,503.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FLUORO 0 1HR TIME PHYS QHCP,3228913,CDM,320,RC,76000,CPT,5523,APC,,,,outpatient,facility,,,553,553,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO PUSH INTRAARTERIAL,3228996,CDM,331,RC,96420,CPT,,,,,,inpatient,facility,,,616,258.72,523.6,591.36,,523.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,535.92,,,percent of total billed charges,,,,,,,,,554.4,,,percent of total billed charges,,,591.36,,,percent of total billed charges,,,585.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,572.88,,,percent of total billed charges,,,585.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO PUSH INTRAARTERIAL,3228996,CDM,331,RC,96420,CPT,,,,,,outpatient,facility,,,616,258.72,166.32,591.36,,523.6,,,percent of total billed charges,,,166.32,,,percent of total billed charges,,,423.81,,,percent of total billed charges,,,414.57,,,percent of total billed charges,,,520.52,,,percent of total billed charges,,,,,,,,,535.92,,,percent of total billed charges,,,535.92,,,percent of total billed charges,,,523.6,,,percent of total billed charges,,,591.36,,,percent of total billed charges,,,585.2,,,percent of total billed charges,,,,,,,,,554.4,,,percent of total billed charges,,,,,,,,,572.88,,,percent of total billed charges,,,585.2,,,percent of total billed charges,,,,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,338.68,,,fee schedule,,,,,,,,,481.1,,,percent of total billed charges,,,560.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO PUSH INTRAARTERIAL,3228996,CDM,331,RC,96420,CPT,5694,APC,,,,outpatient,facility,,,616,616,180.68,501.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,501.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",466.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,345.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,180.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS CATH PLEURAL INDWL W CUFF,3229267,CDM,361,RC,32550,CPT,,,,,,inpatient,facility,,,2787,1170.54,2368.95,2675.52,,2368.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2424.69,,,percent of total billed charges,,,,,,,,,2508.3,,,percent of total billed charges,,,2675.52,,,percent of total billed charges,,,2647.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2591.91,,,percent of total billed charges,,,2647.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS CATH PLEURAL INDWL W CUFF,3229267,CDM,361,RC,32550,CPT,,,,,,outpatient,facility,,,2787,1170.54,752.49,15487,,2368.95,,,percent of total billed charges,,,752.49,,,percent of total billed charges,,,1917.46,,,percent of total billed charges,,,1875.65,,,percent of total billed charges,,,2355.01,,,percent of total billed charges,,,,,,,,,2424.69,,,percent of total billed charges,,,2424.69,,,percent of total billed charges,,,2368.95,,,percent of total billed charges,,,2675.52,,,percent of total billed charges,,,2647.65,,,percent of total billed charges,,,,,,,,,2508.3,,,percent of total billed charges,,,,,,,,,2591.91,,,percent of total billed charges,,,2647.65,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,2536.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS CATH PLEURAL INDWL W CUFF,3229267,CDM,361,RC,32550,CPT,5341,APC,,,,outpatient,facility,,,2787,2787,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL STRICT AND OBSTRUCT INTRALUM S ANDI,3229390,CDM,320,RC,74360,CPT,,,,,,inpatient,facility,,,575,241.5,488.75,552,,488.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,500.25,,,percent of total billed charges,,,,,,,,,517.5,,,percent of total billed charges,,,552,,,percent of total billed charges,,,546.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,534.75,,,percent of total billed charges,,,546.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL STRICT AND OBSTRUCT INTRALUM S ANDI,3229390,CDM,320,RC,74360,CPT,,,,,,outpatient,facility,,,575,241.5,155.25,575,,488.75,,,percent of total billed charges,,,155.25,,,percent of total billed charges,,,395.6,,,percent of total billed charges,,,386.97,,,percent of total billed charges,,,485.88,,,percent of total billed charges,,,,,,,,,500.25,,,percent of total billed charges,,,500.25,,,percent of total billed charges,,,488.75,,,percent of total billed charges,,,552,,,percent of total billed charges,,,546.25,,,percent of total billed charges,,,,,,,,,517.5,,,percent of total billed charges,,,,,,,,,534.75,,,percent of total billed charges,,,546.25,,,percent of total billed charges,,,,,,,,,,,,,,,575,,,fee schedule,,,575,,,fee schedule,,,575,,,fee schedule,,,,,,,,,449.07,,,percent of total billed charges,,,523.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S CNT EVAL CVD FLUORO S ANDI,3229820,CDM,361,RC,36598,CPT,,,,,,inpatient,facility,,,743,312.06,631.55,713.28,,631.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,646.41,,,percent of total billed charges,,,,,,,,,668.7,,,percent of total billed charges,,,713.28,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,690.99,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S CNT EVAL CVD FLUORO S ANDI,3229820,CDM,361,RC,36598,CPT,,,,,,outpatient,facility,,,743,312.06,200.61,3428,,631.55,,,percent of total billed charges,,,200.61,,,percent of total billed charges,,,511.18,,,percent of total billed charges,,,500.04,,,percent of total billed charges,,,627.84,,,percent of total billed charges,,,,,,,,,646.41,,,percent of total billed charges,,,646.41,,,percent of total billed charges,,,631.55,,,percent of total billed charges,,,713.28,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,668.7,,,percent of total billed charges,,,,,,,,,690.99,,,percent of total billed charges,,,705.85,,,percent of total billed charges,,,,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,214.35,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,676.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S CNT EVAL CVD FLUORO S ANDI,3229820,CDM,361,RC,36598,CPT,5693,APC,,,,outpatient,facility,,,743,743,112.21,317.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,317.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",295.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,218.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,112.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBECT MECH PRIM ART SUBSQ W FL,3229846,CDM,361,RC,37185,CPT,,,,,,inpatient,facility,,,3508,1473.36,2981.8,3367.68,,2981.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3051.96,,,percent of total billed charges,,,,,,,,,3157.2,,,percent of total billed charges,,,3367.68,,,percent of total billed charges,,,3332.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3262.44,,,percent of total billed charges,,,3332.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH PRIM ART SUBSQ W FL,3229846,CDM,361,RC,37185,CPT,,,,,,outpatient,facility,,,3508,1473.36,947.16,3508,,2981.8,,,percent of total billed charges,,,947.16,,,percent of total billed charges,,,2413.5,,,percent of total billed charges,,,2360.88,,,percent of total billed charges,,,2964.26,,,percent of total billed charges,,,,,,,,,3051.96,,,percent of total billed charges,,,3051.96,,,percent of total billed charges,,,2981.8,,,percent of total billed charges,,,3367.68,,,percent of total billed charges,,,3332.6,,,percent of total billed charges,,,,,,,,,3157.2,,,percent of total billed charges,,,,,,,,,3262.44,,,percent of total billed charges,,,3332.6,,,percent of total billed charges,,,,,,,,,,,,,,,3508,,,fee schedule,,,3508,,,fee schedule,,,3508,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3192.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH SEC ART W FL,3229853,CDM,361,RC,37186,CPT,,,,,,inpatient,facility,,,9113,3827.46,7746.05,8748.48,,7746.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7928.31,,,percent of total billed charges,,,,,,,,,8201.7,,,percent of total billed charges,,,8748.48,,,percent of total billed charges,,,8657.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8475.09,,,percent of total billed charges,,,8657.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH SEC ART W FL,3229853,CDM,361,RC,37186,CPT,,,,,,outpatient,facility,,,9113,3827.46,2460.51,9113,,7746.05,,,percent of total billed charges,,,2460.51,,,percent of total billed charges,,,6269.74,,,percent of total billed charges,,,6133.05,,,percent of total billed charges,,,7700.48,,,percent of total billed charges,,,,,,,,,7928.31,,,percent of total billed charges,,,7928.31,,,percent of total billed charges,,,7746.05,,,percent of total billed charges,,,8748.48,,,percent of total billed charges,,,8657.35,,,percent of total billed charges,,,,,,,,,8201.7,,,percent of total billed charges,,,,,,,,,8475.09,,,percent of total billed charges,,,8657.35,,,percent of total billed charges,,,,,,,,,,,,,,,9113,,,fee schedule,,,9113,,,fee schedule,,,9113,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,8292.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH VEIN W FL,3229861,CDM,361,RC,37187,CPT,,,,,,inpatient,facility,,,10485,4403.7,8912.25,10065.6,,8912.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9121.95,,,percent of total billed charges,,,,,,,,,9436.5,,,percent of total billed charges,,,10065.6,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9751.05,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH VEIN W FL,3229861,CDM,361,RC,37187,CPT,,,,,,outpatient,facility,,,10485,4403.7,2830.95,28046,,8912.25,,,percent of total billed charges,,,2830.95,,,percent of total billed charges,,,7213.68,,,percent of total billed charges,,,7056.4,,,percent of total billed charges,,,8859.82,,,percent of total billed charges,,,,,,,,,9121.95,,,percent of total billed charges,,,9121.95,,,percent of total billed charges,,,8912.25,,,percent of total billed charges,,,10065.6,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,9436.5,,,percent of total billed charges,,,,,,,,,9751.05,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,,,,,,,10485,,,fee schedule,,,10485,,,fee schedule,,,10485,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,9541.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH VEIN W FL,3229861,CDM,361,RC,37187,CPT,5193,APC,,,,outpatient,facility,,,10485,10485,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBECT MECH VEIN SUBSQ W FL,3229879,CDM,361,RC,37188,CPT,,,,,,inpatient,facility,,,7339,3082.38,6238.15,7045.44,,6238.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6384.93,,,percent of total billed charges,,,,,,,,,6605.1,,,percent of total billed charges,,,7045.44,,,percent of total billed charges,,,6972.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6825.27,,,percent of total billed charges,,,6972.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH VEIN SUBSQ W FL,3229879,CDM,361,RC,37188,CPT,,,,,,outpatient,facility,,,7339,3082.38,1981.53,15487,,6238.15,,,percent of total billed charges,,,1981.53,,,percent of total billed charges,,,5049.23,,,percent of total billed charges,,,4939.15,,,percent of total billed charges,,,6201.45,,,percent of total billed charges,,,,,,,,,6384.93,,,percent of total billed charges,,,6384.93,,,percent of total billed charges,,,6238.15,,,percent of total billed charges,,,7045.44,,,percent of total billed charges,,,6972.05,,,percent of total billed charges,,,,,,,,,6605.1,,,percent of total billed charges,,,,,,,,,6825.27,,,percent of total billed charges,,,6972.05,,,percent of total billed charges,,,,,,,,,,,,,,,7339,,,fee schedule,,,7339,,,fee schedule,,,7339,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6678.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT MECH VEIN SUBSQ W FL,3229879,CDM,361,RC,37188,CPT,5183,APC,,,,outpatient,facility,,,7339,7339,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC STENT URETER INT PERC LT S ANDI,3229895,CDM,361,RC,50382,CPT,,,,,LT  ,inpatient,facility,,,5143,2160.06,4371.55,4937.28,,4371.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4474.41,,,percent of total billed charges,,,,,,,,,4628.7,,,percent of total billed charges,,,4937.28,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4782.99,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER INT PERC LT S ANDI,3229895,CDM,361,RC,50382,CPT,,,,,LT  ,outpatient,facility,,,5143,2160.06,1388.61,11510,,4371.55,,,percent of total billed charges,,,1388.61,,,percent of total billed charges,,,3538.38,,,percent of total billed charges,,,3461.24,,,percent of total billed charges,,,4345.84,,,percent of total billed charges,,,,,,,,,4474.41,,,percent of total billed charges,,,4474.41,,,percent of total billed charges,,,4371.55,,,percent of total billed charges,,,4937.28,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,4628.7,,,percent of total billed charges,,,,,,,,,4782.99,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,4680.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER INT PERC LT S ANDI,3229895,CDM,361,RC,50382,CPT,5373,APC,,,LT  ,outpatient,facility,,,5143,5143,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC STENT URETER INT PERC RT S ANDI,3229903,CDM,361,RC,50382,CPT,,,,,RT  ,inpatient,facility,,,5143,2160.06,4371.55,4937.28,,4371.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4474.41,,,percent of total billed charges,,,,,,,,,4628.7,,,percent of total billed charges,,,4937.28,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4782.99,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER INT PERC RT S ANDI,3229903,CDM,361,RC,50382,CPT,,,,,RT  ,outpatient,facility,,,5143,2160.06,1388.61,11510,,4371.55,,,percent of total billed charges,,,1388.61,,,percent of total billed charges,,,3538.38,,,percent of total billed charges,,,3461.24,,,percent of total billed charges,,,4345.84,,,percent of total billed charges,,,,,,,,,4474.41,,,percent of total billed charges,,,4474.41,,,percent of total billed charges,,,4371.55,,,percent of total billed charges,,,4937.28,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,4628.7,,,percent of total billed charges,,,,,,,,,4782.99,,,percent of total billed charges,,,4885.85,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,4680.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER INT PERC RT S ANDI,3229903,CDM,361,RC,50382,CPT,5373,APC,,,RT  ,outpatient,facility,,,5143,5143,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC STENT URETER INT PERC BI S ANDI,3229911,CDM,361,RC,50382,CPT,,,,,50,inpatient,facility,,,7714,3239.88,6556.9,7405.44,,6556.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6711.18,,,percent of total billed charges,,,,,,,,,6942.6,,,percent of total billed charges,,,7405.44,,,percent of total billed charges,,,7328.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7174.02,,,percent of total billed charges,,,7328.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER INT PERC BI S ANDI,3229911,CDM,361,RC,50382,CPT,,,,,50,outpatient,facility,,,7714,3239.88,2036.88,11510,,6556.9,,,percent of total billed charges,,,2082.78,,,percent of total billed charges,,,5307.23,,,percent of total billed charges,,,5191.52,,,percent of total billed charges,,,6518.33,,,percent of total billed charges,,,,,,,,,6711.18,,,percent of total billed charges,,,6711.18,,,percent of total billed charges,,,6556.9,,,percent of total billed charges,,,7405.44,,,percent of total billed charges,,,7328.3,,,percent of total billed charges,,,,,,,,,6942.6,,,percent of total billed charges,,,,,,,,,7174.02,,,percent of total billed charges,,,7328.3,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,7019.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER INT PERC BI S ANDI,3229911,CDM,361,RC,50382,CPT,5373,APC,,,50,outpatient,facility,,,7714,7714,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM STENT URETER INT PERC LT S ANDI,3229929,CDM,361,RC,50384,CPT,,,,,LT  ,inpatient,facility,,,3967,1666.14,3371.95,3808.32,,3371.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3451.29,,,percent of total billed charges,,,,,,,,,3570.3,,,percent of total billed charges,,,3808.32,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3689.31,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM STENT URETER INT PERC LT S ANDI,3229929,CDM,361,RC,50384,CPT,,,,,LT  ,outpatient,facility,,,3967,1666.14,1071.09,11510,,3371.95,,,percent of total billed charges,,,1071.09,,,percent of total billed charges,,,2729.3,,,percent of total billed charges,,,2669.79,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,,,,,,,3451.29,,,percent of total billed charges,,,3451.29,,,percent of total billed charges,,,3371.95,,,percent of total billed charges,,,3808.32,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,3570.3,,,percent of total billed charges,,,,,,,,,3689.31,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3609.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM STENT URETER INT PERC LT S ANDI,3229929,CDM,361,RC,50384,CPT,5373,APC,,,LT  ,outpatient,facility,,,3967,3967,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM STENT URETER INT PERC RT S ANDI,3229937,CDM,361,RC,50384,CPT,,,,,RT  ,inpatient,facility,,,3967,1666.14,3371.95,3808.32,,3371.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3451.29,,,percent of total billed charges,,,,,,,,,3570.3,,,percent of total billed charges,,,3808.32,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3689.31,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM STENT URETER INT PERC RT S ANDI,3229937,CDM,361,RC,50384,CPT,,,,,RT  ,outpatient,facility,,,3967,1666.14,1071.09,11510,,3371.95,,,percent of total billed charges,,,1071.09,,,percent of total billed charges,,,2729.3,,,percent of total billed charges,,,2669.79,,,percent of total billed charges,,,3352.11,,,percent of total billed charges,,,,,,,,,3451.29,,,percent of total billed charges,,,3451.29,,,percent of total billed charges,,,3371.95,,,percent of total billed charges,,,3808.32,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,3570.3,,,percent of total billed charges,,,,,,,,,3689.31,,,percent of total billed charges,,,3768.65,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3609.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM STENT URETER INT PERC RT S ANDI,3229937,CDM,361,RC,50384,CPT,5373,APC,,,RT  ,outpatient,facility,,,3967,3967,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM STENT URETER INT PERC BI S ANDI,3229945,CDM,361,RC,50384,CPT,,,,,50,inpatient,facility,,,5950,2499,5057.5,5712,,5057.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5176.5,,,percent of total billed charges,,,,,,,,,5355,,,percent of total billed charges,,,5712,,,percent of total billed charges,,,5652.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5533.5,,,percent of total billed charges,,,5652.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM STENT URETER INT PERC BI S ANDI,3229945,CDM,361,RC,50384,CPT,,,,,50,outpatient,facility,,,5950,2499,1606.5,11510,,5057.5,,,percent of total billed charges,,,1606.5,,,percent of total billed charges,,,4093.6,,,percent of total billed charges,,,4004.35,,,percent of total billed charges,,,5027.75,,,percent of total billed charges,,,,,,,,,5176.5,,,percent of total billed charges,,,5176.5,,,percent of total billed charges,,,5057.5,,,percent of total billed charges,,,5712,,,percent of total billed charges,,,5652.5,,,percent of total billed charges,,,,,,,,,5355,,,percent of total billed charges,,,,,,,,,5533.5,,,percent of total billed charges,,,5652.5,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,5414.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM STENT URETER INT PERC BI S ANDI,3229945,CDM,361,RC,50384,CPT,5373,APC,,,50,outpatient,facility,,,5950,5950,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC CATH NEPHROURETER FL GD LT S ANDI,3229952,CDM,361,RC,50387,CPT,,,,,LT  ,inpatient,facility,,,3082,1294.44,2619.7,2958.72,,2619.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.34,,,percent of total billed charges,,,,,,,,,2773.8,,,percent of total billed charges,,,2958.72,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2866.26,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC CATH NEPHROURETER FL GD LT S ANDI,3229952,CDM,361,RC,50387,CPT,,,,,LT  ,outpatient,facility,,,3082,1294.44,832.14,5933,,2619.7,,,percent of total billed charges,,,832.14,,,percent of total billed charges,,,2120.42,,,percent of total billed charges,,,2074.19,,,percent of total billed charges,,,2604.29,,,percent of total billed charges,,,,,,,,,2681.34,,,percent of total billed charges,,,2681.34,,,percent of total billed charges,,,2619.7,,,percent of total billed charges,,,2958.72,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,2773.8,,,percent of total billed charges,,,,,,,,,2866.26,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC CATH NEPHROURETER FL GD LT S ANDI,3229952,CDM,361,RC,50387,CPT,5373,APC,,,LT  ,outpatient,facility,,,3082,3082,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC CATH NEPHROURETER FL GD RT S ANDI,3229960,CDM,361,RC,50387,CPT,,,,,RT  ,inpatient,facility,,,3082,1294.44,2619.7,2958.72,,2619.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2681.34,,,percent of total billed charges,,,,,,,,,2773.8,,,percent of total billed charges,,,2958.72,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2866.26,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC CATH NEPHROURETER FL GD RT S ANDI,3229960,CDM,361,RC,50387,CPT,,,,,RT  ,outpatient,facility,,,3082,1294.44,832.14,5933,,2619.7,,,percent of total billed charges,,,832.14,,,percent of total billed charges,,,2120.42,,,percent of total billed charges,,,2074.19,,,percent of total billed charges,,,2604.29,,,percent of total billed charges,,,,,,,,,2681.34,,,percent of total billed charges,,,2681.34,,,percent of total billed charges,,,2619.7,,,percent of total billed charges,,,2958.72,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,2773.8,,,percent of total billed charges,,,,,,,,,2866.26,,,percent of total billed charges,,,2927.9,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2804.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC CATH NEPHROURETER FL GD RT S ANDI,3229960,CDM,361,RC,50387,CPT,5373,APC,,,RT  ,outpatient,facility,,,3082,3082,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC CATH NEPHROURETER FL GD BI S ANDI,3229978,CDM,361,RC,50387,CPT,,,,,50,inpatient,facility,,,4622,1941.24,3928.7,4437.12,,3928.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4021.14,,,percent of total billed charges,,,,,,,,,4159.8,,,percent of total billed charges,,,4437.12,,,percent of total billed charges,,,4390.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4298.46,,,percent of total billed charges,,,4390.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC CATH NEPHROURETER FL GD BI S ANDI,3229978,CDM,361,RC,50387,CPT,,,,,50,outpatient,facility,,,4622,1941.24,1247.94,5933,,3928.7,,,percent of total billed charges,,,1247.94,,,percent of total billed charges,,,3179.94,,,percent of total billed charges,,,3110.61,,,percent of total billed charges,,,3905.59,,,percent of total billed charges,,,,,,,,,4021.14,,,percent of total billed charges,,,4021.14,,,percent of total billed charges,,,3928.7,,,percent of total billed charges,,,4437.12,,,percent of total billed charges,,,4390.9,,,percent of total billed charges,,,,,,,,,4159.8,,,percent of total billed charges,,,,,,,,,4298.46,,,percent of total billed charges,,,4390.9,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,4206.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC CATH NEPHROURETER FL GD BI S ANDI,3229978,CDM,361,RC,50387,CPT,5373,APC,,,50,outpatient,facility,,,4622,4622,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM TUBE NEPHRO W FLUORO LT S ANDI,3229986,CDM,361,RC,50389,CPT,,,,,LT  ,inpatient,facility,,,1538,645.96,1307.3,1476.48,,1307.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1338.06,,,percent of total billed charges,,,,,,,,,1384.2,,,percent of total billed charges,,,1476.48,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1430.34,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM TUBE NEPHRO W FLUORO LT S ANDI,3229986,CDM,361,RC,50389,CPT,,,,,LT  ,outpatient,facility,,,1538,645.96,415.26,3522,,1307.3,,,percent of total billed charges,,,415.26,,,percent of total billed charges,,,1058.14,,,percent of total billed charges,,,1035.07,,,percent of total billed charges,,,1299.61,,,percent of total billed charges,,,,,,,,,1338.06,,,percent of total billed charges,,,1338.06,,,percent of total billed charges,,,1307.3,,,percent of total billed charges,,,1476.48,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,1384.2,,,percent of total billed charges,,,,,,,,,1430.34,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1399.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM TUBE NEPHRO W FLUORO LT S ANDI,3229986,CDM,361,RC,50389,CPT,5372,APC,,,LT  ,outpatient,facility,,,1538,1538,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM TUBE NEPHRO W FLUORO RT S ANDI,3229994,CDM,361,RC,50389,CPT,,,,,RT  ,inpatient,facility,,,1538,645.96,1307.3,1476.48,,1307.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1338.06,,,percent of total billed charges,,,,,,,,,1384.2,,,percent of total billed charges,,,1476.48,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1430.34,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM TUBE NEPHRO W FLUORO RT S ANDI,3229994,CDM,361,RC,50389,CPT,,,,,RT  ,outpatient,facility,,,1538,645.96,415.26,3522,,1307.3,,,percent of total billed charges,,,415.26,,,percent of total billed charges,,,1058.14,,,percent of total billed charges,,,1035.07,,,percent of total billed charges,,,1299.61,,,percent of total billed charges,,,,,,,,,1338.06,,,percent of total billed charges,,,1338.06,,,percent of total billed charges,,,1307.3,,,percent of total billed charges,,,1476.48,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,1384.2,,,percent of total billed charges,,,,,,,,,1430.34,,,percent of total billed charges,,,1461.1,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1399.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM TUBE NEPHRO W FLUORO RT S ANDI,3229994,CDM,361,RC,50389,CPT,5372,APC,,,RT  ,outpatient,facility,,,1538,1538,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM TUBE NEPHRO W FLUORO BI S ANDI,3230000,CDM,361,RC,50389,CPT,,,,,50,inpatient,facility,,,2307,968.94,1960.95,2214.72,,1960.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2007.09,,,percent of total billed charges,,,,,,,,,2076.3,,,percent of total billed charges,,,2214.72,,,percent of total billed charges,,,2191.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2145.51,,,percent of total billed charges,,,2191.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM TUBE NEPHRO W FLUORO BI S ANDI,3230000,CDM,361,RC,50389,CPT,,,,,50,outpatient,facility,,,2307,968.94,622.89,3522,,1960.95,,,percent of total billed charges,,,622.89,,,percent of total billed charges,,,1587.22,,,percent of total billed charges,,,1552.61,,,percent of total billed charges,,,1949.41,,,percent of total billed charges,,,,,,,,,2007.09,,,percent of total billed charges,,,2007.09,,,percent of total billed charges,,,1960.95,,,percent of total billed charges,,,2214.72,,,percent of total billed charges,,,2191.65,,,percent of total billed charges,,,,,,,,,2076.3,,,percent of total billed charges,,,,,,,,,2145.51,,,percent of total billed charges,,,2191.65,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2099.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM TUBE NEPHRO W FLUORO BI S ANDI,3230000,CDM,361,RC,50389,CPT,5372,APC,,,50,outpatient,facility,,,2307,2307,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHG TB STNT URETER CONDUIT ILEAL,3230133,CDM,361,RC,50688,CPT,,,,,,inpatient,facility,,,3238,1359.96,2752.3,3108.48,,2752.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2817.06,,,percent of total billed charges,,,,,,,,,2914.2,,,percent of total billed charges,,,3108.48,,,percent of total billed charges,,,3076.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3011.34,,,percent of total billed charges,,,3076.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHG TB STNT URETER CONDUIT ILEAL,3230133,CDM,361,RC,50688,CPT,,,,,,outpatient,facility,,,3238,1359.96,874.26,5933,,2752.3,,,percent of total billed charges,,,874.26,,,percent of total billed charges,,,2227.74,,,percent of total billed charges,,,2179.17,,,percent of total billed charges,,,2736.11,,,percent of total billed charges,,,,,,,,,2817.06,,,percent of total billed charges,,,2817.06,,,percent of total billed charges,,,2752.3,,,percent of total billed charges,,,3108.48,,,percent of total billed charges,,,3076.1,,,percent of total billed charges,,,,,,,,,2914.2,,,percent of total billed charges,,,,,,,,,3011.34,,,percent of total billed charges,,,3076.1,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2946.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHG TB STNT URETER CONDUIT ILEAL,3230133,CDM,361,RC,50688,CPT,5373,APC,,,,outpatient,facility,,,3238,3238,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TURCICA SELLA,3231198,CDM,320,RC,70240,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TURCICA SELLA,3231198,CDM,320,RC,70240,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TURCICA SELLA,3231198,CDM,320,RC,70240,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ CYST GANGLION,3234630,CDM,361,RC,20612,CPT,,,,,,inpatient,facility,,,527,221.34,447.95,505.92,,447.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,458.49,,,percent of total billed charges,,,,,,,,,474.3,,,percent of total billed charges,,,505.92,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,490.11,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST GANGLION,3234630,CDM,361,RC,20612,CPT,,,,,,outpatient,facility,,,527,221.34,142.29,3428,,447.95,,,percent of total billed charges,,,142.29,,,percent of total billed charges,,,362.58,,,percent of total billed charges,,,354.67,,,percent of total billed charges,,,445.31,,,percent of total billed charges,,,,,,,,,458.49,,,percent of total billed charges,,,458.49,,,percent of total billed charges,,,447.95,,,percent of total billed charges,,,505.92,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,474.3,,,percent of total billed charges,,,,,,,,,490.11,,,percent of total billed charges,,,500.65,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,479.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ CYST GANGLION,3234630,CDM,361,RC,20612,CPT,5441,APC,,,,outpatient,facility,,,527,527,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
I ANDR FB TISSUE SUBQ SIMPLE,3234705,CDM,361,RC,10120,CPT,,,,,,inpatient,facility,,,319,133.98,271.15,306.24,,271.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,277.53,,,percent of total billed charges,,,,,,,,,287.1,,,percent of total billed charges,,,306.24,,,percent of total billed charges,,,303.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,296.67,,,percent of total billed charges,,,303.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
I ANDR FB TISSUE SUBQ SIMPLE,3234705,CDM,361,RC,10120,CPT,,,,,,outpatient,facility,,,319,133.98,86.13,3428,,271.15,,,percent of total billed charges,,,86.13,,,percent of total billed charges,,,219.47,,,percent of total billed charges,,,214.69,,,percent of total billed charges,,,269.56,,,percent of total billed charges,,,,,,,,,277.53,,,percent of total billed charges,,,277.53,,,percent of total billed charges,,,271.15,,,percent of total billed charges,,,306.24,,,percent of total billed charges,,,303.05,,,percent of total billed charges,,,,,,,,,287.1,,,percent of total billed charges,,,,,,,,,296.67,,,percent of total billed charges,,,303.05,,,percent of total billed charges,,,,,,,,,,,,,,,406.89,,,fee schedule,,,406.89,,,fee schedule,,,398.75,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,290.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
I ANDR FB TISSUE SUBQ SIMPLE,3234705,CDM,361,RC,10120,CPT,5052,APC,,,,outpatient,facility,,,319,319,202.65,589.99,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,406.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,415.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,406.89,,,fee schedule,,,,,,,,,,,,,,,589.99,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",549.3,,,fee schedule,,,,,,,,,,,,,,,,,,,,,406.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,406.89,,,fee schedule,,,406.89,,,fee schedule,,,202.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS TUBE GASTRO PERC S ANDI,3234754,CDM,361,RC,49440,CPT,,,,,,inpatient,facility,,,2271,953.82,1930.35,2180.16,,1930.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1975.77,,,percent of total billed charges,,,,,,,,,2043.9,,,percent of total billed charges,,,2180.16,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2112.03,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS TUBE GASTRO PERC S ANDI,3234754,CDM,361,RC,49440,CPT,,,,,,outpatient,facility,,,2271,953.82,613.17,5933,,1930.35,,,percent of total billed charges,,,613.17,,,percent of total billed charges,,,1562.45,,,percent of total billed charges,,,1528.38,,,percent of total billed charges,,,1918.99,,,percent of total billed charges,,,,,,,,,1975.77,,,percent of total billed charges,,,1975.77,,,percent of total billed charges,,,1930.35,,,percent of total billed charges,,,2180.16,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,2043.9,,,percent of total billed charges,,,,,,,,,2112.03,,,percent of total billed charges,,,2157.45,,,percent of total billed charges,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,1902.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2066.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS TUBE GASTRO PERC S ANDI,3234754,CDM,361,RC,49440,CPT,5302,APC,,,,outpatient,facility,,,2271,2271,946.03,2815.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,2815.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2621.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1941.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,946.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS TUBE DUO JEJUNOSTOMY PERC S ANDI,3234762,CDM,361,RC,49441,CPT,,,,,,inpatient,facility,,,2657,1115.94,2258.45,2550.72,,2258.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2311.59,,,percent of total billed charges,,,,,,,,,2391.3,,,percent of total billed charges,,,2550.72,,,percent of total billed charges,,,2524.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2471.01,,,percent of total billed charges,,,2524.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS TUBE DUO JEJUNOSTOMY PERC S ANDI,3234762,CDM,361,RC,49441,CPT,,,,,,outpatient,facility,,,2657,1115.94,717.39,5933,,2258.45,,,percent of total billed charges,,,717.39,,,percent of total billed charges,,,1828.02,,,percent of total billed charges,,,1788.16,,,percent of total billed charges,,,2245.16,,,percent of total billed charges,,,,,,,,,2311.59,,,percent of total billed charges,,,2311.59,,,percent of total billed charges,,,2258.45,,,percent of total billed charges,,,2550.72,,,percent of total billed charges,,,2524.15,,,percent of total billed charges,,,,,,,,,2391.3,,,percent of total billed charges,,,,,,,,,2471.01,,,percent of total billed charges,,,2524.15,,,percent of total billed charges,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,1902.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2417.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS TUBE DUO JEJUNOSTOMY PERC S ANDI,3234762,CDM,361,RC,49441,CPT,5302,APC,,,,outpatient,facility,,,2657,2657,946.03,2815.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,2815.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2621.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1941.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,946.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHG G TUBE TO G J TUBE PERC S ANDI,3234788,CDM,361,RC,49446,CPT,,,,,,inpatient,facility,,,1635,686.7,1389.75,1569.6,,1389.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1422.45,,,percent of total billed charges,,,,,,,,,1471.5,,,percent of total billed charges,,,1569.6,,,percent of total billed charges,,,1553.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1520.55,,,percent of total billed charges,,,1553.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHG G TUBE TO G J TUBE PERC S ANDI,3234788,CDM,361,RC,49446,CPT,,,,,,outpatient,facility,,,1635,686.7,441.45,5933,,1389.75,,,percent of total billed charges,,,441.45,,,percent of total billed charges,,,1124.88,,,percent of total billed charges,,,1100.35,,,percent of total billed charges,,,1381.58,,,percent of total billed charges,,,,,,,,,1422.45,,,percent of total billed charges,,,1422.45,,,percent of total billed charges,,,1389.75,,,percent of total billed charges,,,1569.6,,,percent of total billed charges,,,1553.25,,,percent of total billed charges,,,,,,,,,1471.5,,,percent of total billed charges,,,,,,,,,1520.55,,,percent of total billed charges,,,1553.25,,,percent of total billed charges,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,1902.88,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1487.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHG G TUBE TO G J TUBE PERC S ANDI,3234788,CDM,361,RC,49446,CPT,5302,APC,,,,outpatient,facility,,,1635,1635,946.03,2815.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1941.71,,,fee schedule,,,,,,,,,,,,,,,2815.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2621.31,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1941.71,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1941.71,,,fee schedule,,,1941.71,,,fee schedule,,,946.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC TUBE GASTRO CECOSTOMY PERC S ANDI,3234796,CDM,361,RC,49450,CPT,,,,,,inpatient,facility,,,727,305.34,617.95,697.92,,617.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.49,,,percent of total billed charges,,,,,,,,,654.3,,,percent of total billed charges,,,697.92,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,676.11,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC TUBE GASTRO CECOSTOMY PERC S ANDI,3234796,CDM,361,RC,49450,CPT,,,,,,outpatient,facility,,,727,305.34,196.29,5933,,617.95,,,percent of total billed charges,,,196.29,,,percent of total billed charges,,,500.18,,,percent of total billed charges,,,489.27,,,percent of total billed charges,,,614.31,,,percent of total billed charges,,,,,,,,,632.49,,,percent of total billed charges,,,632.49,,,percent of total billed charges,,,617.95,,,percent of total billed charges,,,697.92,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,654.3,,,percent of total billed charges,,,,,,,,,676.11,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,661.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC TUBE GASTRO CECOSTOMY PERC S ANDI,3234796,CDM,361,RC,49450,CPT,5301,APC,,,,outpatient,facility,,,727,727,448.42,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,448.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC TUBE DUO JEJUNOSTOMY PERC S ANDI,3234804,CDM,361,RC,49451,CPT,,,,,,inpatient,facility,,,1000,420,850,960,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC TUBE DUO JEJUNOSTOMY PERC S ANDI,3234804,CDM,361,RC,49451,CPT,,,,,,outpatient,facility,,,1000,420,270,5933,,850,,,percent of total billed charges,,,270,,,percent of total billed charges,,,688,,,percent of total billed charges,,,673,,,percent of total billed charges,,,845,,,percent of total billed charges,,,,,,,,,870,,,percent of total billed charges,,,870,,,percent of total billed charges,,,850,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC TUBE DUO JEJUNOSTOMY PERC S ANDI,3234804,CDM,361,RC,49451,CPT,5301,APC,,,,outpatient,facility,,,1000,1000,448.42,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,448.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC TUBE G J PERC S ANDI,3234812,CDM,361,RC,49452,CPT,,,,,,inpatient,facility,,,1522,639.24,1293.7,1461.12,,1293.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1324.14,,,percent of total billed charges,,,,,,,,,1369.8,,,percent of total billed charges,,,1461.12,,,percent of total billed charges,,,1445.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1415.46,,,percent of total billed charges,,,1445.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC TUBE G J PERC S ANDI,3234812,CDM,361,RC,49452,CPT,,,,,,outpatient,facility,,,1522,639.24,410.94,5933,,1293.7,,,percent of total billed charges,,,410.94,,,percent of total billed charges,,,1047.14,,,percent of total billed charges,,,1024.31,,,percent of total billed charges,,,1286.09,,,percent of total billed charges,,,,,,,,,1324.14,,,percent of total billed charges,,,1324.14,,,percent of total billed charges,,,1293.7,,,percent of total billed charges,,,1461.12,,,percent of total billed charges,,,1445.9,,,percent of total billed charges,,,,,,,,,1369.8,,,percent of total billed charges,,,,,,,,,1415.46,,,percent of total billed charges,,,1445.9,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1385.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC TUBE G J PERC S ANDI,3234812,CDM,361,RC,49452,CPT,5301,APC,,,,outpatient,facility,,,1522,1522,448.42,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,448.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ CNT TUBE G COLON PERC S ANDI,3234838,CDM,361,RC,49465,CPT,,,,,,inpatient,facility,,,341,143.22,289.85,327.36,,289.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,296.67,,,percent of total billed charges,,,,,,,,,306.9,,,percent of total billed charges,,,327.36,,,percent of total billed charges,,,323.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,317.13,,,percent of total billed charges,,,323.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CNT TUBE G COLON PERC S ANDI,3234838,CDM,361,RC,49465,CPT,,,,,,outpatient,facility,,,341,143.22,92.07,3428,,289.85,,,percent of total billed charges,,,92.07,,,percent of total billed charges,,,234.61,,,percent of total billed charges,,,229.49,,,percent of total billed charges,,,288.14,,,percent of total billed charges,,,,,,,,,296.67,,,percent of total billed charges,,,296.67,,,percent of total billed charges,,,289.85,,,percent of total billed charges,,,327.36,,,percent of total billed charges,,,323.95,,,percent of total billed charges,,,,,,,,,306.9,,,percent of total billed charges,,,,,,,,,317.13,,,percent of total billed charges,,,323.95,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,310.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ CNT TUBE G COLON PERC S ANDI,3234838,CDM,361,RC,49465,CPT,5523,APC,,,,outpatient,facility,,,341,341,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO INF INTRAARTERIAL 1ST HR,3235058,CDM,335,RC,96422,CPT,,,,,,inpatient,facility,,,727,305.34,617.95,697.92,,617.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.49,,,percent of total billed charges,,,,,,,,,654.3,,,percent of total billed charges,,,697.92,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,676.11,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO INF INTRAARTERIAL 1ST HR,3235058,CDM,335,RC,96422,CPT,,,,,,outpatient,facility,,,727,305.34,196.29,697.92,,617.95,,,percent of total billed charges,,,196.29,,,percent of total billed charges,,,500.18,,,percent of total billed charges,,,489.27,,,percent of total billed charges,,,614.31,,,percent of total billed charges,,,,,,,,,632.49,,,percent of total billed charges,,,632.49,,,percent of total billed charges,,,617.95,,,percent of total billed charges,,,697.92,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,654.3,,,percent of total billed charges,,,,,,,,,676.11,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,338.68,,,fee schedule,,,,,,,,,567.79,,,percent of total billed charges,,,661.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO INF INTRAARTERIAL 1ST HR,3235058,CDM,335,RC,96422,CPT,5694,APC,,,,outpatient,facility,,,727,727,180.68,501.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,501.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",466.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,345.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,180.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DISCOGRAM CERVICAL THORACIC S ANDI,3235249,CDM,320,RC,72285,CPT,,,,,,inpatient,facility,,,5582,2344.44,4744.7,5358.72,,4744.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4856.34,,,percent of total billed charges,,,,,,,,,5023.8,,,percent of total billed charges,,,5358.72,,,percent of total billed charges,,,5302.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5191.26,,,percent of total billed charges,,,5302.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DISCOGRAM CERVICAL THORACIC S ANDI,3235249,CDM,320,RC,72285,CPT,,,,,,outpatient,facility,,,5582,2344.44,1507.14,5358.72,,4744.7,,,percent of total billed charges,,,1507.14,,,percent of total billed charges,,,3840.42,,,percent of total billed charges,,,3756.69,,,percent of total billed charges,,,4716.79,,,percent of total billed charges,,,,,,,,,4856.34,,,percent of total billed charges,,,4856.34,,,percent of total billed charges,,,4744.7,,,percent of total billed charges,,,5358.72,,,percent of total billed charges,,,5302.9,,,percent of total billed charges,,,,,,,,,5023.8,,,percent of total billed charges,,,,,,,,,5191.26,,,percent of total billed charges,,,5302.9,,,percent of total billed charges,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,1930.84,,,fee schedule,,,,,,,,,4359.54,,,percent of total billed charges,,,5079.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DISCOGRAM CERVICAL THORACIC S ANDI,3235249,CDM,320,RC,72285,CPT,5431,APC,,,,outpatient,facility,,,5582,5582,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PERITONEOGRAM S ANDI,3235256,CDM,320,RC,74190,CPT,,,,,,inpatient,facility,,,491,206.22,417.35,471.36,,417.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,427.17,,,percent of total billed charges,,,,,,,,,441.9,,,percent of total billed charges,,,471.36,,,percent of total billed charges,,,466.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,456.63,,,percent of total billed charges,,,466.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PERITONEOGRAM S ANDI,3235256,CDM,320,RC,74190,CPT,,,,,,outpatient,facility,,,491,206.22,132.57,562.95,,417.35,,,percent of total billed charges,,,132.57,,,percent of total billed charges,,,337.81,,,percent of total billed charges,,,330.44,,,percent of total billed charges,,,414.89,,,percent of total billed charges,,,,,,,,,427.17,,,percent of total billed charges,,,427.17,,,percent of total billed charges,,,417.35,,,percent of total billed charges,,,471.36,,,percent of total billed charges,,,466.45,,,percent of total billed charges,,,,,,,,,441.9,,,percent of total billed charges,,,,,,,,,456.63,,,percent of total billed charges,,,466.45,,,percent of total billed charges,,,,,,,,,,,,,,,562.95,,,fee schedule,,,562.95,,,fee schedule,,,551.69,,,fee schedule,,,,,,,,,383.47,,,percent of total billed charges,,,446.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PERITONEOGRAM S ANDI,3235256,CDM,320,RC,74190,CPT,5524,APC,,,,outpatient,facility,,,491,491,273.3,816.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,562.95,,,fee schedule,,,,,,,,,,,,,,,816.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",759.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,562.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,562.95,,,fee schedule,,,562.95,,,fee schedule,,,273.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD PEDIATRICS PVT,32367,CDM,113,RC,,,,,,,,inpatient,facility,,,2200,924,1870,2200,,1870,,,percent of total billed charges,,,,,,,,,2200,,,case rate,,,2200,,,case rate,,,,,,,,,,,,,,,1914,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,2112,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,1980,,,percent of total billed charges,,,,,,,,,2046,,,percent of total billed charges,,,2090,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2200,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC PROS PROX RPR EV AO THOR S ANDI,3237260,CDM,320,RC,75958,CPT,,,,,,inpatient,facility,,,1849,776.58,1571.65,1775.04,,1571.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1608.63,,,percent of total billed charges,,,,,,,,,1664.1,,,percent of total billed charges,,,1775.04,,,percent of total billed charges,,,1756.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1719.57,,,percent of total billed charges,,,1756.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC PROS PROX RPR EV AO THOR S ANDI,3237260,CDM,320,RC,75958,CPT,,,,,,outpatient,facility,,,1849,776.58,499.23,1849,,1571.65,,,percent of total billed charges,,,499.23,,,percent of total billed charges,,,1272.11,,,percent of total billed charges,,,1244.38,,,percent of total billed charges,,,1562.4,,,percent of total billed charges,,,,,,,,,1608.63,,,percent of total billed charges,,,1608.63,,,percent of total billed charges,,,1571.65,,,percent of total billed charges,,,1775.04,,,percent of total billed charges,,,1756.55,,,percent of total billed charges,,,,,,,,,1664.1,,,percent of total billed charges,,,,,,,,,1719.57,,,percent of total billed charges,,,1756.55,,,percent of total billed charges,,,,,,,,,,,,,,,1849,,,fee schedule,,,1849,,,fee schedule,,,1849,,,fee schedule,,,,,,,,,1444.07,,,percent of total billed charges,,,1682.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 1 LVL BI,3241551,CDM,361,RC,64490,CPT,,,,,50,inpatient,facility,,,2923,1227.66,2484.55,2806.08,,2484.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2543.01,,,percent of total billed charges,,,,,,,,,2630.7,,,percent of total billed charges,,,2806.08,,,percent of total billed charges,,,2776.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2718.39,,,percent of total billed charges,,,2776.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 1 LVL BI,3241551,CDM,361,RC,64490,CPT,,,,,50,outpatient,facility,,,2923,1227.66,789.21,3522,,2484.55,,,percent of total billed charges,,,789.21,,,percent of total billed charges,,,2011.02,,,percent of total billed charges,,,1967.18,,,percent of total billed charges,,,2469.93,,,percent of total billed charges,,,,,,,,,2543.01,,,percent of total billed charges,,,2543.01,,,percent of total billed charges,,,2484.55,,,percent of total billed charges,,,2806.08,,,percent of total billed charges,,,2776.85,,,percent of total billed charges,,,,,,,,,2630.7,,,percent of total billed charges,,,,,,,,,2718.39,,,percent of total billed charges,,,2776.85,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2659.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 1 LVL BI,3241551,CDM,361,RC,64490,CPT,5443,APC,,,50,outpatient,facility,,,2923,2923,694.36,2022.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,2022.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1883.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1395.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1395.16,,,fee schedule,,,1395.16,,,fee schedule,,,694.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S JT FCT C T IMG 1 LVL LT,3241569,CDM,361,RC,64490,CPT,,,,,LT  ,inpatient,facility,,,1949,818.58,1656.65,1871.04,,1656.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1695.63,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 1 LVL LT,3241569,CDM,361,RC,64490,CPT,,,,,LT  ,outpatient,facility,,,1949,818.58,526.23,3522,,1656.65,,,percent of total billed charges,,,526.23,,,percent of total billed charges,,,1340.91,,,percent of total billed charges,,,1311.68,,,percent of total billed charges,,,1646.9,,,percent of total billed charges,,,,,,,,,1695.63,,,percent of total billed charges,,,1695.63,,,percent of total billed charges,,,1656.65,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1773.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 1 LVL LT,3241569,CDM,361,RC,64490,CPT,5443,APC,,,LT  ,outpatient,facility,,,1949,1949,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S JT FCT C T IMG 1 LVL RT,3241577,CDM,361,RC,64490,CPT,,,,,RT  ,inpatient,facility,,,1949,818.58,1656.65,1871.04,,1656.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1695.63,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 1 LVL RT,3241577,CDM,361,RC,64490,CPT,,,,,RT  ,outpatient,facility,,,1949,818.58,526.23,3522,,1656.65,,,percent of total billed charges,,,526.23,,,percent of total billed charges,,,1340.91,,,percent of total billed charges,,,1311.68,,,percent of total billed charges,,,1646.9,,,percent of total billed charges,,,,,,,,,1695.63,,,percent of total billed charges,,,1695.63,,,percent of total billed charges,,,1656.65,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1773.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 1 LVL RT,3241577,CDM,361,RC,64490,CPT,5443,APC,,,RT  ,outpatient,facility,,,1949,1949,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S JT FCT C T IMG 2 LVL BI,3241585,CDM,361,RC,64491,CPT,,,,,50,inpatient,facility,,,3215,1350.3,2732.75,3086.4,,2732.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2797.05,,,percent of total billed charges,,,,,,,,,2893.5,,,percent of total billed charges,,,3086.4,,,percent of total billed charges,,,3054.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2989.95,,,percent of total billed charges,,,3054.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 2 LVL BI,3241585,CDM,361,RC,64491,CPT,,,,,50,outpatient,facility,,,3215,1350.3,868.05,3428,,2732.75,,,percent of total billed charges,,,868.05,,,percent of total billed charges,,,2211.92,,,percent of total billed charges,,,2163.69,,,percent of total billed charges,,,2716.67,,,percent of total billed charges,,,,,,,,,2797.05,,,percent of total billed charges,,,2797.05,,,percent of total billed charges,,,2732.75,,,percent of total billed charges,,,3086.4,,,percent of total billed charges,,,3054.25,,,percent of total billed charges,,,,,,,,,2893.5,,,percent of total billed charges,,,,,,,,,2989.95,,,percent of total billed charges,,,3054.25,,,percent of total billed charges,,,,,,,,,,,,,,,3215,,,fee schedule,,,3215,,,fee schedule,,,3215,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2925.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 2 LVL LT,3241593,CDM,361,RC,64491,CPT,,,,,LT  ,inpatient,facility,,,2144,900.48,1822.4,2058.24,,1822.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1865.28,,,percent of total billed charges,,,,,,,,,1929.6,,,percent of total billed charges,,,2058.24,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1993.92,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 2 LVL LT,3241593,CDM,361,RC,64491,CPT,,,,,LT  ,outpatient,facility,,,2144,900.48,578.88,3428,,1822.4,,,percent of total billed charges,,,578.88,,,percent of total billed charges,,,1475.07,,,percent of total billed charges,,,1442.91,,,percent of total billed charges,,,1811.68,,,percent of total billed charges,,,,,,,,,1865.28,,,percent of total billed charges,,,1865.28,,,percent of total billed charges,,,1822.4,,,percent of total billed charges,,,2058.24,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,1929.6,,,percent of total billed charges,,,,,,,,,1993.92,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,,,,,,,2144,,,fee schedule,,,2144,,,fee schedule,,,2144,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1951.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 2 LVL RT,3241601,CDM,361,RC,64491,CPT,,,,,RT  ,inpatient,facility,,,2144,900.48,1822.4,2058.24,,1822.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1865.28,,,percent of total billed charges,,,,,,,,,1929.6,,,percent of total billed charges,,,2058.24,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1993.92,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 2 LVL RT,3241601,CDM,361,RC,64491,CPT,,,,,RT  ,outpatient,facility,,,2144,900.48,578.88,3428,,1822.4,,,percent of total billed charges,,,578.88,,,percent of total billed charges,,,1475.07,,,percent of total billed charges,,,1442.91,,,percent of total billed charges,,,1811.68,,,percent of total billed charges,,,,,,,,,1865.28,,,percent of total billed charges,,,1865.28,,,percent of total billed charges,,,1822.4,,,percent of total billed charges,,,2058.24,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,1929.6,,,percent of total billed charges,,,,,,,,,1993.92,,,percent of total billed charges,,,2036.8,,,percent of total billed charges,,,,,,,,,,,,,,,2144,,,fee schedule,,,2144,,,fee schedule,,,2144,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1951.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 3 PLUS LVL BI,3241619,CDM,361,RC,64492,CPT,,,,,50,inpatient,facility,,,3507,1472.94,2980.95,3366.72,,2980.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3051.09,,,percent of total billed charges,,,,,,,,,3156.3,,,percent of total billed charges,,,3366.72,,,percent of total billed charges,,,3331.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3261.51,,,percent of total billed charges,,,3331.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 3 PLUS LVL BI,3241619,CDM,361,RC,64492,CPT,,,,,50,outpatient,facility,,,3507,1472.94,946.89,3507,,2980.95,,,percent of total billed charges,,,946.89,,,percent of total billed charges,,,2412.82,,,percent of total billed charges,,,2360.21,,,percent of total billed charges,,,2963.41,,,percent of total billed charges,,,,,,,,,3051.09,,,percent of total billed charges,,,3051.09,,,percent of total billed charges,,,2980.95,,,percent of total billed charges,,,3366.72,,,percent of total billed charges,,,3331.65,,,percent of total billed charges,,,,,,,,,3156.3,,,percent of total billed charges,,,,,,,,,3261.51,,,percent of total billed charges,,,3331.65,,,percent of total billed charges,,,,,,,,,,,,,,,3507,,,fee schedule,,,3507,,,fee schedule,,,3507,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3191.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 3 PLUS LVL LT,3241627,CDM,361,RC,64492,CPT,,,,,LT  ,inpatient,facility,,,2338,981.96,1987.3,2244.48,,1987.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2034.06,,,percent of total billed charges,,,,,,,,,2104.2,,,percent of total billed charges,,,2244.48,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.34,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 3 PLUS LVL LT,3241627,CDM,361,RC,64492,CPT,,,,,LT  ,outpatient,facility,,,2338,981.96,631.26,3428,,1987.3,,,percent of total billed charges,,,631.26,,,percent of total billed charges,,,1608.54,,,percent of total billed charges,,,1573.47,,,percent of total billed charges,,,1975.61,,,percent of total billed charges,,,,,,,,,2034.06,,,percent of total billed charges,,,2034.06,,,percent of total billed charges,,,1987.3,,,percent of total billed charges,,,2244.48,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,2104.2,,,percent of total billed charges,,,,,,,,,2174.34,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,,,,,,,2338,,,fee schedule,,,2338,,,fee schedule,,,2338,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2127.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 3 PLUS LVL RT,3241635,CDM,361,RC,64492,CPT,,,,,RT  ,inpatient,facility,,,2338,981.96,1987.3,2244.48,,1987.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2034.06,,,percent of total billed charges,,,,,,,,,2104.2,,,percent of total billed charges,,,2244.48,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2174.34,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT C T IMG 3 PLUS LVL RT,3241635,CDM,361,RC,64492,CPT,,,,,RT  ,outpatient,facility,,,2338,981.96,631.26,3428,,1987.3,,,percent of total billed charges,,,631.26,,,percent of total billed charges,,,1608.54,,,percent of total billed charges,,,1573.47,,,percent of total billed charges,,,1975.61,,,percent of total billed charges,,,,,,,,,2034.06,,,percent of total billed charges,,,2034.06,,,percent of total billed charges,,,1987.3,,,percent of total billed charges,,,2244.48,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,2104.2,,,percent of total billed charges,,,,,,,,,2174.34,,,percent of total billed charges,,,2221.1,,,percent of total billed charges,,,,,,,,,,,,,,,2338,,,fee schedule,,,2338,,,fee schedule,,,2338,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2127.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 1 LVL BI,3241643,CDM,361,RC,64493,CPT,,,,,50,inpatient,facility,,,2630,1104.6,2235.5,2524.8,,2235.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2288.1,,,percent of total billed charges,,,,,,,,,2367,,,percent of total billed charges,,,2524.8,,,percent of total billed charges,,,2498.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2445.9,,,percent of total billed charges,,,2498.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 1 LVL BI,3241643,CDM,361,RC,64493,CPT,,,,,50,outpatient,facility,,,2630,1104.6,710.1,3522,,2235.5,,,percent of total billed charges,,,710.1,,,percent of total billed charges,,,1809.44,,,percent of total billed charges,,,1769.99,,,percent of total billed charges,,,2222.35,,,percent of total billed charges,,,,,,,,,2288.1,,,percent of total billed charges,,,2288.1,,,percent of total billed charges,,,2235.5,,,percent of total billed charges,,,2524.8,,,percent of total billed charges,,,2498.5,,,percent of total billed charges,,,,,,,,,2367,,,percent of total billed charges,,,,,,,,,2445.9,,,percent of total billed charges,,,2498.5,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2393.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 1 LVL BI,3241643,CDM,361,RC,64493,CPT,5443,APC,,,50,outpatient,facility,,,2630,2630,694.36,2022.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,2022.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1883.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1395.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1395.16,,,fee schedule,,,1395.16,,,fee schedule,,,694.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S JT FCT L S IMG 1 LVL LT,3241650,CDM,361,RC,64493,CPT,,,,,LT  ,inpatient,facility,,,1754,736.68,1490.9,1683.84,,1490.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1525.98,,,percent of total billed charges,,,,,,,,,1578.6,,,percent of total billed charges,,,1683.84,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1631.22,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 1 LVL LT,3241650,CDM,361,RC,64493,CPT,,,,,LT  ,outpatient,facility,,,1754,736.68,473.58,3522,,1490.9,,,percent of total billed charges,,,473.58,,,percent of total billed charges,,,1206.75,,,percent of total billed charges,,,1180.44,,,percent of total billed charges,,,1482.13,,,percent of total billed charges,,,,,,,,,1525.98,,,percent of total billed charges,,,1525.98,,,percent of total billed charges,,,1490.9,,,percent of total billed charges,,,1683.84,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,1578.6,,,percent of total billed charges,,,,,,,,,1631.22,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1596.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 1 LVL LT,3241650,CDM,361,RC,64493,CPT,5443,APC,,,LT  ,outpatient,facility,,,1754,1754,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S JT FCT L S IMG 1 LVL RT,3241668,CDM,361,RC,64493,CPT,,,,,RT  ,inpatient,facility,,,1754,736.68,1490.9,1683.84,,1490.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1525.98,,,percent of total billed charges,,,,,,,,,1578.6,,,percent of total billed charges,,,1683.84,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1631.22,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 1 LVL RT,3241668,CDM,361,RC,64493,CPT,,,,,RT  ,outpatient,facility,,,1754,736.68,473.58,3522,,1490.9,,,percent of total billed charges,,,473.58,,,percent of total billed charges,,,1206.75,,,percent of total billed charges,,,1180.44,,,percent of total billed charges,,,1482.13,,,percent of total billed charges,,,,,,,,,1525.98,,,percent of total billed charges,,,1525.98,,,percent of total billed charges,,,1490.9,,,percent of total billed charges,,,1683.84,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,1578.6,,,percent of total billed charges,,,,,,,,,1631.22,,,percent of total billed charges,,,1666.3,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1596.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 1 LVL RT,3241668,CDM,361,RC,64493,CPT,5443,APC,,,RT  ,outpatient,facility,,,1754,1754,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S JT FCT L S IMG 2 LVL BI,3241676,CDM,361,RC,64494,CPT,,,,,50,inpatient,facility,,,1500,630,1275,1440,,1275,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1305,,,percent of total billed charges,,,,,,,,,1350,,,percent of total billed charges,,,1440,,,percent of total billed charges,,,1425,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1395,,,percent of total billed charges,,,1425,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 2 LVL BI,3241676,CDM,361,RC,64494,CPT,,,,,50,outpatient,facility,,,1500,630,405,3428,,1275,,,percent of total billed charges,,,405,,,percent of total billed charges,,,1032,,,percent of total billed charges,,,1009.5,,,percent of total billed charges,,,1267.5,,,percent of total billed charges,,,,,,,,,1305,,,percent of total billed charges,,,1305,,,percent of total billed charges,,,1275,,,percent of total billed charges,,,1440,,,percent of total billed charges,,,1425,,,percent of total billed charges,,,,,,,,,1350,,,percent of total billed charges,,,,,,,,,1395,,,percent of total billed charges,,,1425,,,percent of total billed charges,,,,,,,,,,,,,,,1500,,,fee schedule,,,1500,,,fee schedule,,,1500,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1365,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 2 LVL LT,3241684,CDM,361,RC,64494,CPT,,,,,LT  ,inpatient,facility,,,1000,420,850,960,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 2 LVL LT,3241684,CDM,361,RC,64494,CPT,,,,,LT  ,outpatient,facility,,,1000,420,270,3428,,850,,,percent of total billed charges,,,270,,,percent of total billed charges,,,688,,,percent of total billed charges,,,673,,,percent of total billed charges,,,845,,,percent of total billed charges,,,,,,,,,870,,,percent of total billed charges,,,870,,,percent of total billed charges,,,850,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,1000,,,fee schedule,,,1000,,,fee schedule,,,1000,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 2 LVL RT,3241692,CDM,361,RC,64494,CPT,,,,,RT  ,inpatient,facility,,,1000,420,850,960,,850,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,870,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 2 LVL RT,3241692,CDM,361,RC,64494,CPT,,,,,RT  ,outpatient,facility,,,1000,420,270,3428,,850,,,percent of total billed charges,,,270,,,percent of total billed charges,,,688,,,percent of total billed charges,,,673,,,percent of total billed charges,,,845,,,percent of total billed charges,,,,,,,,,870,,,percent of total billed charges,,,870,,,percent of total billed charges,,,850,,,percent of total billed charges,,,960,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,900,,,percent of total billed charges,,,,,,,,,930,,,percent of total billed charges,,,950,,,percent of total billed charges,,,,,,,,,,,,,,,1000,,,fee schedule,,,1000,,,fee schedule,,,1000,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,910,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 3 PLUS LVL BI,3241700,CDM,361,RC,64495,CPT,,,,,50,inpatient,facility,,,1526,640.92,1297.1,1464.96,,1297.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1327.62,,,percent of total billed charges,,,,,,,,,1373.4,,,percent of total billed charges,,,1464.96,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1419.18,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 3 PLUS LVL BI,3241700,CDM,361,RC,64495,CPT,,,,,50,outpatient,facility,,,1526,640.92,412.02,3428,,1297.1,,,percent of total billed charges,,,412.02,,,percent of total billed charges,,,1049.89,,,percent of total billed charges,,,1027,,,percent of total billed charges,,,1289.47,,,percent of total billed charges,,,,,,,,,1327.62,,,percent of total billed charges,,,1327.62,,,percent of total billed charges,,,1297.1,,,percent of total billed charges,,,1464.96,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,1373.4,,,percent of total billed charges,,,,,,,,,1419.18,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,,,,,,,1526,,,fee schedule,,,1526,,,fee schedule,,,1526,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1388.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 3 PLUS LVL LT,3241718,CDM,361,RC,64495,CPT,,,,,LT  ,inpatient,facility,,,1017,427.14,864.45,976.32,,864.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.79,,,percent of total billed charges,,,,,,,,,915.3,,,percent of total billed charges,,,976.32,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,945.81,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 3 PLUS LVL LT,3241718,CDM,361,RC,64495,CPT,,,,,LT  ,outpatient,facility,,,1017,427.14,274.59,3428,,864.45,,,percent of total billed charges,,,274.59,,,percent of total billed charges,,,699.7,,,percent of total billed charges,,,684.44,,,percent of total billed charges,,,859.37,,,percent of total billed charges,,,,,,,,,884.79,,,percent of total billed charges,,,884.79,,,percent of total billed charges,,,864.45,,,percent of total billed charges,,,976.32,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,915.3,,,percent of total billed charges,,,,,,,,,945.81,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,,,,,,,1017,,,fee schedule,,,1017,,,fee schedule,,,1017,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,925.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 3 PLUS LVL RT,3241726,CDM,361,RC,64495,CPT,,,,,RT  ,inpatient,facility,,,1017,427.14,864.45,976.32,,864.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,884.79,,,percent of total billed charges,,,,,,,,,915.3,,,percent of total billed charges,,,976.32,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,945.81,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S JT FCT L S IMG 3 PLUS LVL RT,3241726,CDM,361,RC,64495,CPT,,,,,RT  ,outpatient,facility,,,1017,427.14,274.59,3428,,864.45,,,percent of total billed charges,,,274.59,,,percent of total billed charges,,,699.7,,,percent of total billed charges,,,684.44,,,percent of total billed charges,,,859.37,,,percent of total billed charges,,,,,,,,,884.79,,,percent of total billed charges,,,884.79,,,percent of total billed charges,,,864.45,,,percent of total billed charges,,,976.32,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,915.3,,,percent of total billed charges,,,,,,,,,945.81,,,percent of total billed charges,,,966.15,,,percent of total billed charges,,,,,,,,,,,,,,,1017,,,fee schedule,,,1017,,,fee schedule,,,1017,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,925.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM CATH PLEURAL INDWL W CUFF,3241916,CDM,361,RC,32552,CPT,,,,,,inpatient,facility,,,1204,505.68,1023.4,1155.84,,1023.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1047.48,,,percent of total billed charges,,,,,,,,,1083.6,,,percent of total billed charges,,,1155.84,,,percent of total billed charges,,,1143.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1119.72,,,percent of total billed charges,,,1143.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM CATH PLEURAL INDWL W CUFF,3241916,CDM,361,RC,32552,CPT,,,,,,outpatient,facility,,,1204,505.68,325.08,3522,,1023.4,,,percent of total billed charges,,,325.08,,,percent of total billed charges,,,828.35,,,percent of total billed charges,,,810.29,,,percent of total billed charges,,,1017.38,,,percent of total billed charges,,,,,,,,,1047.48,,,percent of total billed charges,,,1047.48,,,percent of total billed charges,,,1023.4,,,percent of total billed charges,,,1155.84,,,percent of total billed charges,,,1143.8,,,percent of total billed charges,,,,,,,,,1083.6,,,percent of total billed charges,,,,,,,,,1119.72,,,percent of total billed charges,,,1143.8,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1095.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM CATH PLEURAL INDWL W CUFF,3241916,CDM,361,RC,32552,CPT,5181,APC,,,,outpatient,facility,,,1204,1204,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPECIMEN SURGICAL,3241973,CDM,320,RC,76098,CPT,,,,,,inpatient,facility,,,237,99.54,201.45,227.52,,201.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.19,,,percent of total billed charges,,,,,,,,,213.3,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPECIMEN SURGICAL,3241973,CDM,320,RC,76098,CPT,,,,,,outpatient,facility,,,237,99.54,63.99,562.95,,201.45,,,percent of total billed charges,,,63.99,,,percent of total billed charges,,,163.06,,,percent of total billed charges,,,159.5,,,percent of total billed charges,,,200.26,,,percent of total billed charges,,,,,,,,,206.19,,,percent of total billed charges,,,206.19,,,percent of total billed charges,,,201.45,,,percent of total billed charges,,,227.52,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,213.3,,,percent of total billed charges,,,,,,,,,220.41,,,percent of total billed charges,,,225.15,,,percent of total billed charges,,,,,,,,,,,,,,,562.95,,,fee schedule,,,562.95,,,fee schedule,,,551.69,,,fee schedule,,,,,,,,,185.1,,,percent of total billed charges,,,215.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPECIMEN SURGICAL,3241973,CDM,320,RC,76098,CPT,5524,APC,,,,outpatient,facility,,,237,237,273.3,816.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.95,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,562.95,,,fee schedule,,,,,,,,,,,,,,,816.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",759.98,,,fee schedule,,,,,,,,,,,,,,,,,,,,,562.95,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,562.95,,,fee schedule,,,562.95,,,fee schedule,,,273.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR EYE FOREIGN BODY LT,3242237,CDM,320,RC,70030,CPT,,,,,LT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR EYE FOREIGN BODY LT,3242237,CDM,320,RC,70030,CPT,,,,,LT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR EYE FOREIGN BODY LT,3242237,CDM,320,RC,70030,CPT,5521,APC,,,LT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR EYE FOREIGN BODY RT,3242245,CDM,320,RC,70030,CPT,,,,,RT  ,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR EYE FOREIGN BODY RT,3242245,CDM,320,RC,70030,CPT,,,,,RT  ,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR EYE FOREIGN BODY RT,3242245,CDM,320,RC,70030,CPT,5521,APC,,,RT  ,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD ICU,32433,CDM,200,RC,,,,,,,,inpatient,facility,,,6600,2772,5610,6600,,5610,,,percent of total billed charges,,,,,,,,,6600,,,case rate,,,6600,,,case rate,,,,,,,,,,,,,,,5742,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,6336,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,,,,,,,6138,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6600,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR RIBS W CXR 3 PLUS VW,3243326,CDM,320,RC,71101,CPT,,,,,,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR RIBS W CXR 3 PLUS VW,3243326,CDM,320,RC,71101,CPT,,,,,,outpatient,facility,,,115,48.3,31.05,112.19,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,,,,,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR RIBS W CXR 3 PLUS VW,3243326,CDM,320,RC,71101,CPT,5522,APC,,,,outpatient,facility,,,115,115,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX PANCREAS NDL PERC,3243342,CDM,361,RC,48102,CPT,,,,,,inpatient,facility,,,1906,800.52,1620.1,1829.76,,1620.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1658.22,,,percent of total billed charges,,,,,,,,,1715.4,,,percent of total billed charges,,,1829.76,,,percent of total billed charges,,,1810.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1772.58,,,percent of total billed charges,,,1810.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX PANCREAS NDL PERC,3243342,CDM,361,RC,48102,CPT,,,,,,outpatient,facility,,,1906,800.52,514.62,5933,,1620.1,,,percent of total billed charges,,,514.62,,,percent of total billed charges,,,1311.33,,,percent of total billed charges,,,1282.74,,,percent of total billed charges,,,1610.57,,,percent of total billed charges,,,,,,,,,1658.22,,,percent of total billed charges,,,1658.22,,,percent of total billed charges,,,1620.1,,,percent of total billed charges,,,1829.76,,,percent of total billed charges,,,1810.7,,,percent of total billed charges,,,,,,,,,1715.4,,,percent of total billed charges,,,,,,,,,1772.58,,,percent of total billed charges,,,1810.7,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1734.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX PANCREAS NDL PERC,3243342,CDM,361,RC,48102,CPT,5072,APC,,,,outpatient,facility,,,1906,1906,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT GD PLCMT NEEDLE S ANDI,3243359,CDM,350,RC,77012,CPT,,,,,,inpatient,facility,,,1341,563.22,1139.85,1287.36,,1139.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1166.67,,,percent of total billed charges,,,,,,,,,1206.9,,,percent of total billed charges,,,1287.36,,,percent of total billed charges,,,1273.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1247.13,,,percent of total billed charges,,,1273.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT GD PLCMT NEEDLE S ANDI,3243359,CDM,350,RC,77012,CPT,,,,,,outpatient,facility,,,1341,563.22,362.07,1341,,1139.85,,,percent of total billed charges,,,362.07,,,percent of total billed charges,,,922.61,,,percent of total billed charges,,,902.49,,,percent of total billed charges,,,1133.14,,,percent of total billed charges,,,,,,,,,1166.67,,,percent of total billed charges,,,1166.67,,,percent of total billed charges,,,1139.85,,,percent of total billed charges,,,1287.36,,,percent of total billed charges,,,1273.95,,,percent of total billed charges,,,,,,,,,1206.9,,,percent of total billed charges,,,,,,,,,1247.13,,,percent of total billed charges,,,1273.95,,,percent of total billed charges,,,,,,,,,,,,,,,1341,,,fee schedule,,,1341,,,fee schedule,,,1341,,,fee schedule,,,,,,,,,1047.32,,,percent of total billed charges,,,1220.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR MASTOIDS CMP 3 PLUS VW PER SIDE LT,3243979,CDM,320,RC,70130,CPT,,,,,LT  ,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR MASTOIDS CMP 3 PLUS VW PER SIDE LT,3243979,CDM,320,RC,70130,CPT,,,,,LT  ,outpatient,facility,,,115,48.3,31.05,112.19,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,,,,,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR MASTOIDS CMP 3 PLUS VW PER SIDE LT,3243979,CDM,320,RC,70130,CPT,5522,APC,,,LT  ,outpatient,facility,,,115,115,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR MASTOIDS CMP 3 PLUS VW PER SIDE RT,3243987,CDM,320,RC,70130,CPT,,,,,RT  ,inpatient,facility,,,115,48.3,97.75,110.4,,97.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,100.05,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR MASTOIDS CMP 3 PLUS VW PER SIDE RT,3243987,CDM,320,RC,70130,CPT,,,,,RT  ,outpatient,facility,,,115,48.3,31.05,112.19,,97.75,,,percent of total billed charges,,,31.05,,,percent of total billed charges,,,79.12,,,percent of total billed charges,,,77.39,,,percent of total billed charges,,,97.17,,,percent of total billed charges,,,,,,,,,100.05,,,percent of total billed charges,,,100.05,,,percent of total billed charges,,,97.75,,,percent of total billed charges,,,110.4,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,103.5,,,percent of total billed charges,,,,,,,,,106.95,,,percent of total billed charges,,,109.25,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,89.81,,,percent of total billed charges,,,104.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR MASTOIDS CMP 3 PLUS VW PER SIDE RT,3243987,CDM,320,RC,70130,CPT,5522,APC,,,RT  ,outpatient,facility,,,115,115,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX S MARROW BONE DX NP UNI,3244969,CDM,361,RC,38221,CPT,,,,,,inpatient,facility,,,1305,548.1,1109.25,1252.8,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.35,,,percent of total billed charges,,,,,,,,,1174.5,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1213.65,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX S MARROW BONE DX NP UNI,3244969,CDM,361,RC,38221,CPT,,,,,,outpatient,facility,,,1305,548.1,352.35,3522,,1109.25,,,percent of total billed charges,,,352.35,,,percent of total billed charges,,,897.84,,,percent of total billed charges,,,878.26,,,percent of total billed charges,,,1102.72,,,percent of total billed charges,,,,,,,,,1135.35,,,percent of total billed charges,,,1135.35,,,percent of total billed charges,,,1109.25,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,1174.5,,,percent of total billed charges,,,,,,,,,1213.65,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1187.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX S MARROW BONE DX NP UNI,3244969,CDM,361,RC,38221,CPT,5072,APC,,,,outpatient,facility,,,1305,1305,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX S MARROW BONE DX BI,3244977,CDM,361,RC,38221,CPT,,,,,50,inpatient,facility,,,1957,821.94,1663.45,1878.72,,1663.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1702.59,,,percent of total billed charges,,,,,,,,,1761.3,,,percent of total billed charges,,,1878.72,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1820.01,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX S MARROW BONE DX BI,3244977,CDM,361,RC,38221,CPT,,,,,50,outpatient,facility,,,1957,821.94,528.39,3522,,1663.45,,,percent of total billed charges,,,528.39,,,percent of total billed charges,,,1346.42,,,percent of total billed charges,,,1317.06,,,percent of total billed charges,,,1653.66,,,percent of total billed charges,,,,,,,,,1702.59,,,percent of total billed charges,,,1702.59,,,percent of total billed charges,,,1663.45,,,percent of total billed charges,,,1878.72,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,1761.3,,,percent of total billed charges,,,,,,,,,1820.01,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1780.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX S MARROW BONE DX BI,3244977,CDM,361,RC,38221,CPT,5072,APC,,,50,outpatient,facility,,,1957,1957,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP S ANDBX S MARROW BONE DX BI,3244985,CDM,361,RC,38222,CPT,,,,,50,inpatient,facility,,,1957,821.94,1663.45,1878.72,,1663.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1702.59,,,percent of total billed charges,,,,,,,,,1761.3,,,percent of total billed charges,,,1878.72,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1820.01,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP S ANDBX S MARROW BONE DX BI,3244985,CDM,361,RC,38222,CPT,,,,,50,outpatient,facility,,,1957,821.94,528.39,5933,,1663.45,,,percent of total billed charges,,,528.39,,,percent of total billed charges,,,1346.42,,,percent of total billed charges,,,1317.06,,,percent of total billed charges,,,1653.66,,,percent of total billed charges,,,,,,,,,1702.59,,,percent of total billed charges,,,1702.59,,,percent of total billed charges,,,1663.45,,,percent of total billed charges,,,1878.72,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,1761.3,,,percent of total billed charges,,,,,,,,,1820.01,,,percent of total billed charges,,,1859.15,,,percent of total billed charges,,,,,,,,,,,,,,,2899.57,,,fee schedule,,,2899.57,,,fee schedule,,,2841.58,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1780.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP S ANDBX S MARROW BONE DX BI,3244985,CDM,361,RC,38222,CPT,5073,APC,,,50,outpatient,facility,,,1957,1957,1403.23,4204.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2899.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2957.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2899.57,,,fee schedule,,,,,,,,,,,,,,,4204.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3914.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2899.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2899.57,,,fee schedule,,,2899.57,,,fee schedule,,,1403.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR CHEST 1 VW,3244993,CDM,324,RC,71045,CPT,,,,,,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CHEST 1 VW,3244993,CDM,324,RC,71045,CPT,,,,,,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CHEST 1 VW,3244993,CDM,324,RC,71045,CPT,5521,APC,,,,outpatient,facility,,,111,111,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR CHEST 2 VW,3245016,CDM,324,RC,71046,CPT,,,,,,inpatient,facility,,,141,59.22,119.85,135.36,,119.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.67,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CHEST 2 VW,3245016,CDM,324,RC,71046,CPT,,,,,,outpatient,facility,,,141,59.22,38.07,135.36,,119.85,,,percent of total billed charges,,,38.07,,,percent of total billed charges,,,97.01,,,percent of total billed charges,,,94.89,,,percent of total billed charges,,,119.14,,,percent of total billed charges,,,,,,,,,122.67,,,percent of total billed charges,,,122.67,,,percent of total billed charges,,,119.85,,,percent of total billed charges,,,135.36,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,126.9,,,percent of total billed charges,,,,,,,,,131.13,,,percent of total billed charges,,,133.95,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,110.12,,,percent of total billed charges,,,128.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CHEST 2 VW,3245016,CDM,324,RC,71046,CPT,5521,APC,,,,outpatient,facility,,,141,141,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR CHEST 3 VW,3245032,CDM,324,RC,71047,CPT,,,,,,inpatient,facility,,,178,74.76,151.3,170.88,,151.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,154.86,,,percent of total billed charges,,,,,,,,,160.2,,,percent of total billed charges,,,170.88,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,165.54,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CHEST 3 VW,3245032,CDM,324,RC,71047,CPT,,,,,,outpatient,facility,,,178,74.76,48.06,170.88,,151.3,,,percent of total billed charges,,,48.06,,,percent of total billed charges,,,122.46,,,percent of total billed charges,,,119.79,,,percent of total billed charges,,,150.41,,,percent of total billed charges,,,,,,,,,154.86,,,percent of total billed charges,,,154.86,,,percent of total billed charges,,,151.3,,,percent of total billed charges,,,170.88,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,160.2,,,percent of total billed charges,,,,,,,,,165.54,,,percent of total billed charges,,,169.1,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,139.02,,,percent of total billed charges,,,161.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CHEST 3 VW,3245032,CDM,324,RC,71047,CPT,5521,APC,,,,outpatient,facility,,,178,178,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR CHEST 4 PLUS VW,3245057,CDM,324,RC,71048,CPT,,,,,,inpatient,facility,,,192,80.64,163.2,184.32,,163.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,167.04,,,percent of total billed charges,,,,,,,,,172.8,,,percent of total billed charges,,,184.32,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,178.56,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR CHEST 4 PLUS VW,3245057,CDM,324,RC,71048,CPT,,,,,,outpatient,facility,,,192,80.64,51.84,184.32,,163.2,,,percent of total billed charges,,,51.84,,,percent of total billed charges,,,132.1,,,percent of total billed charges,,,129.22,,,percent of total billed charges,,,162.24,,,percent of total billed charges,,,,,,,,,167.04,,,percent of total billed charges,,,167.04,,,percent of total billed charges,,,163.2,,,percent of total billed charges,,,184.32,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,172.8,,,percent of total billed charges,,,,,,,,,178.56,,,percent of total billed charges,,,182.4,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,149.95,,,percent of total billed charges,,,174.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR CHEST 4 PLUS VW,3245057,CDM,324,RC,71048,CPT,5522,APC,,,,outpatient,facility,,,192,192,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBECT ASPIRATION IMG GD,3245073,CDM,361,RC,37799,CPT,,,,,,inpatient,facility,,,10485,4403.7,8912.25,10065.6,,8912.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9121.95,,,percent of total billed charges,,,,,,,,,9436.5,,,percent of total billed charges,,,10065.6,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9751.05,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBECT ASPIRATION IMG GD,3245073,CDM,361,RC,37799,CPT,,,,,,outpatient,facility,,,10485,4403.7,628.23,10065.6,,8912.25,,,percent of total billed charges,,,2830.95,,,percent of total billed charges,,,7213.68,,,percent of total billed charges,,,7056.4,,,percent of total billed charges,,,8859.82,,,percent of total billed charges,,,,,,,,,9121.95,,,percent of total billed charges,,,9121.95,,,percent of total billed charges,,,8912.25,,,percent of total billed charges,,,10065.6,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,9436.5,,,percent of total billed charges,,,,,,,,,9751.05,,,percent of total billed charges,,,9960.75,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,9541.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBECT ASPIRATION IMG GD,3245073,CDM,361,RC,37799,CPT,5181,APC,,,,outpatient,facility,,,10485,10485,641.05,7339.5,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,7339.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP S ANDBX S MARROW BONE DX NP UNI,3245297,CDM,361,RC,38222,CPT,,,,,,inpatient,facility,,,1305,548.1,1109.25,1252.8,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.35,,,percent of total billed charges,,,,,,,,,1174.5,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1213.65,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP S ANDBX S MARROW BONE DX NP UNI,3245297,CDM,361,RC,38222,CPT,,,,,,outpatient,facility,,,1305,548.1,352.35,5933,,1109.25,,,percent of total billed charges,,,352.35,,,percent of total billed charges,,,897.84,,,percent of total billed charges,,,878.26,,,percent of total billed charges,,,1102.72,,,percent of total billed charges,,,,,,,,,1135.35,,,percent of total billed charges,,,1135.35,,,percent of total billed charges,,,1109.25,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,1174.5,,,percent of total billed charges,,,,,,,,,1213.65,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,2899.57,,,fee schedule,,,2899.57,,,fee schedule,,,2841.58,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1187.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP S ANDBX S MARROW BONE DX NP UNI,3245297,CDM,361,RC,38222,CPT,5073,APC,,,,outpatient,facility,,,1305,1305,1403.23,4204.38,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2899.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2957.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2899.57,,,fee schedule,,,,,,,,,,,,,,,4204.38,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",3914.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2899.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2899.57,,,fee schedule,,,2899.57,,,fee schedule,,,1403.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ABDOMEN 1 VW,3245479,CDM,320,RC,74018,CPT,,,,,,inpatient,facility,,,101,42.42,85.85,96.96,,85.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87.87,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN 1 VW,3245479,CDM,320,RC,74018,CPT,,,,,,outpatient,facility,,,101,42.42,27.27,96.96,,85.85,,,percent of total billed charges,,,27.27,,,percent of total billed charges,,,69.49,,,percent of total billed charges,,,67.97,,,percent of total billed charges,,,85.34,,,percent of total billed charges,,,,,,,,,87.87,,,percent of total billed charges,,,87.87,,,percent of total billed charges,,,85.85,,,percent of total billed charges,,,96.96,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,90.9,,,percent of total billed charges,,,,,,,,,93.93,,,percent of total billed charges,,,95.95,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,78.88,,,percent of total billed charges,,,91.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN 1 VW,3245479,CDM,320,RC,74018,CPT,5521,APC,,,,outpatient,facility,,,101,101,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ABDOMEN 2 VW,3245495,CDM,320,RC,74019,CPT,,,,,,inpatient,facility,,,184,77.28,156.4,176.64,,156.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.08,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN 2 VW,3245495,CDM,320,RC,74019,CPT,,,,,,outpatient,facility,,,184,77.28,49.68,176.64,,156.4,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,126.59,,,percent of total billed charges,,,123.83,,,percent of total billed charges,,,155.48,,,percent of total billed charges,,,,,,,,,160.08,,,percent of total billed charges,,,160.08,,,percent of total billed charges,,,156.4,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,143.7,,,percent of total billed charges,,,167.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN 2 VW,3245495,CDM,320,RC,74019,CPT,5522,APC,,,,outpatient,facility,,,184,184,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ABDOMEN 3 PLUS VW,3245511,CDM,320,RC,74021,CPT,,,,,,inpatient,facility,,,184,77.28,156.4,176.64,,156.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,160.08,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN 3 PLUS VW,3245511,CDM,320,RC,74021,CPT,,,,,,outpatient,facility,,,184,77.28,49.68,176.64,,156.4,,,percent of total billed charges,,,49.68,,,percent of total billed charges,,,126.59,,,percent of total billed charges,,,123.83,,,percent of total billed charges,,,155.48,,,percent of total billed charges,,,,,,,,,160.08,,,percent of total billed charges,,,160.08,,,percent of total billed charges,,,156.4,,,percent of total billed charges,,,176.64,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,165.6,,,percent of total billed charges,,,,,,,,,171.12,,,percent of total billed charges,,,174.8,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,143.7,,,percent of total billed charges,,,167.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ABDOMEN 3 PLUS VW,3245511,CDM,320,RC,74021,CPT,5522,APC,,,,outpatient,facility,,,184,184,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBOLYSIS INF CATH PERITONEAL,3245586,CDM,361,RC,49999,CPT,,,,,,inpatient,facility,,,775,325.5,658.75,744,,658.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,674.25,,,percent of total billed charges,,,,,,,,,697.5,,,percent of total billed charges,,,744,,,percent of total billed charges,,,736.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,720.75,,,percent of total billed charges,,,736.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF CATH PERITONEAL,3245586,CDM,361,RC,49999,CPT,,,,,,outpatient,facility,,,775,325.5,209.25,5933,,658.75,,,percent of total billed charges,,,209.25,,,percent of total billed charges,,,533.2,,,percent of total billed charges,,,521.57,,,percent of total billed charges,,,654.88,,,percent of total billed charges,,,,,,,,,674.25,,,percent of total billed charges,,,674.25,,,percent of total billed charges,,,658.75,,,percent of total billed charges,,,744,,,percent of total billed charges,,,736.25,,,percent of total billed charges,,,,,,,,,697.5,,,percent of total billed charges,,,,,,,,,720.75,,,percent of total billed charges,,,736.25,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF CATH PERITONEAL,3245586,CDM,361,RC,49999,CPT,5301,APC,,,,outpatient,facility,,,775,775,542.5,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,542.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX GLAND SALIVARY NDL,3245677,CDM,361,RC,42400,CPT,,,,,,inpatient,facility,,,1684,707.28,1431.4,1616.64,,1431.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1465.08,,,percent of total billed charges,,,,,,,,,1515.6,,,percent of total billed charges,,,1616.64,,,percent of total billed charges,,,1599.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1566.12,,,percent of total billed charges,,,1599.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX GLAND SALIVARY NDL,3245677,CDM,361,RC,42400,CPT,,,,,,outpatient,facility,,,1684,707.28,454.68,3522,,1431.4,,,percent of total billed charges,,,454.68,,,percent of total billed charges,,,1158.59,,,percent of total billed charges,,,1133.33,,,percent of total billed charges,,,1422.98,,,percent of total billed charges,,,,,,,,,1465.08,,,percent of total billed charges,,,1465.08,,,percent of total billed charges,,,1431.4,,,percent of total billed charges,,,1616.64,,,percent of total billed charges,,,1599.8,,,percent of total billed charges,,,,,,,,,1515.6,,,percent of total billed charges,,,,,,,,,1566.12,,,percent of total billed charges,,,1599.8,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1532.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX GLAND SALIVARY NDL,3245677,CDM,361,RC,42400,CPT,5071,APC,,,,outpatient,facility,,,1684,1684,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX EXCISE NODE NDL SUPERFICIAL BI,3246139,CDM,361,RC,38505,CPT,,,,,50,inpatient,facility,,,2619,1099.98,2226.15,2514.24,,2226.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2278.53,,,percent of total billed charges,,,,,,,,,2357.1,,,percent of total billed charges,,,2514.24,,,percent of total billed charges,,,2488.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2435.67,,,percent of total billed charges,,,2488.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX EXCISE NODE NDL SUPERFICIAL BI,3246139,CDM,361,RC,38505,CPT,,,,,50,outpatient,facility,,,2619,1099.98,707.13,5933,,2226.15,,,percent of total billed charges,,,707.13,,,percent of total billed charges,,,1801.87,,,percent of total billed charges,,,1762.59,,,percent of total billed charges,,,2213.05,,,percent of total billed charges,,,,,,,,,2278.53,,,percent of total billed charges,,,2278.53,,,percent of total billed charges,,,2226.15,,,percent of total billed charges,,,2514.24,,,percent of total billed charges,,,2488.05,,,percent of total billed charges,,,,,,,,,2357.1,,,percent of total billed charges,,,,,,,,,2435.67,,,percent of total billed charges,,,2488.05,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2383.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX EXCISE NODE NDL SUPERFICIAL BI,3246139,CDM,361,RC,38505,CPT,5072,APC,,,50,outpatient,facility,,,2619,2619,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX EXCISE NODE NDL SUPERFICIAL LT,3246147,CDM,361,RC,38505,CPT,,,,,LT  ,inpatient,facility,,,1746,733.32,1484.1,1676.16,,1484.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1519.02,,,percent of total billed charges,,,,,,,,,1571.4,,,percent of total billed charges,,,1676.16,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1623.78,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX EXCISE NODE NDL SUPERFICIAL LT,3246147,CDM,361,RC,38505,CPT,,,,,LT  ,outpatient,facility,,,1746,733.32,471.42,5933,,1484.1,,,percent of total billed charges,,,471.42,,,percent of total billed charges,,,1201.25,,,percent of total billed charges,,,1175.06,,,percent of total billed charges,,,1475.37,,,percent of total billed charges,,,,,,,,,1519.02,,,percent of total billed charges,,,1519.02,,,percent of total billed charges,,,1484.1,,,percent of total billed charges,,,1676.16,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,1571.4,,,percent of total billed charges,,,,,,,,,1623.78,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1588.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX EXCISE NODE NDL SUPERFICIAL LT,3246147,CDM,361,RC,38505,CPT,5072,APC,,,LT  ,outpatient,facility,,,1746,1746,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX EXCISE NODE NDL SUPERFICIAL RT,3246154,CDM,361,RC,38505,CPT,,,,,RT  ,inpatient,facility,,,1746,733.32,1484.1,1676.16,,1484.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1519.02,,,percent of total billed charges,,,,,,,,,1571.4,,,percent of total billed charges,,,1676.16,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1623.78,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX EXCISE NODE NDL SUPERFICIAL RT,3246154,CDM,361,RC,38505,CPT,,,,,RT  ,outpatient,facility,,,1746,733.32,471.42,5933,,1484.1,,,percent of total billed charges,,,471.42,,,percent of total billed charges,,,1201.25,,,percent of total billed charges,,,1175.06,,,percent of total billed charges,,,1475.37,,,percent of total billed charges,,,,,,,,,1519.02,,,percent of total billed charges,,,1519.02,,,percent of total billed charges,,,1484.1,,,percent of total billed charges,,,1676.16,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,1571.4,,,percent of total billed charges,,,,,,,,,1623.78,,,percent of total billed charges,,,1658.7,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1588.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX EXCISE NODE NDL SUPERFICIAL RT,3246154,CDM,361,RC,38505,CPT,5072,APC,,,RT  ,outpatient,facility,,,1746,1746,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
STUDY MANOMETRIC RENAL TB CATH BI,3246253,CDM,361,RC,50396,CPT,,,,,50,inpatient,facility,,,1119,469.98,951.15,1074.24,,951.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,973.53,,,percent of total billed charges,,,,,,,,,1007.1,,,percent of total billed charges,,,1074.24,,,percent of total billed charges,,,1063.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1040.67,,,percent of total billed charges,,,1063.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STUDY MANOMETRIC RENAL TB CATH BI,3246253,CDM,361,RC,50396,CPT,,,,,50,outpatient,facility,,,1119,469.98,302.13,3522,,951.15,,,percent of total billed charges,,,302.13,,,percent of total billed charges,,,769.87,,,percent of total billed charges,,,753.09,,,percent of total billed charges,,,945.55,,,percent of total billed charges,,,,,,,,,973.53,,,percent of total billed charges,,,973.53,,,percent of total billed charges,,,951.15,,,percent of total billed charges,,,1074.24,,,percent of total billed charges,,,1063.05,,,percent of total billed charges,,,,,,,,,1007.1,,,percent of total billed charges,,,,,,,,,1040.67,,,percent of total billed charges,,,1063.05,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1018.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STUDY MANOMETRIC RENAL TB CATH BI,3246253,CDM,361,RC,50396,CPT,5372,APC,,,50,outpatient,facility,,,1119,1119,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
STUDY MANOMETRIC RENAL TB CATH LT,3246261,CDM,361,RC,50396,CPT,,,,,LT  ,inpatient,facility,,,746,313.32,634.1,716.16,,634.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.02,,,percent of total billed charges,,,,,,,,,671.4,,,percent of total billed charges,,,716.16,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,693.78,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STUDY MANOMETRIC RENAL TB CATH LT,3246261,CDM,361,RC,50396,CPT,,,,,LT  ,outpatient,facility,,,746,313.32,201.42,3522,,634.1,,,percent of total billed charges,,,201.42,,,percent of total billed charges,,,513.25,,,percent of total billed charges,,,502.06,,,percent of total billed charges,,,630.37,,,percent of total billed charges,,,,,,,,,649.02,,,percent of total billed charges,,,649.02,,,percent of total billed charges,,,634.1,,,percent of total billed charges,,,716.16,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,671.4,,,percent of total billed charges,,,,,,,,,693.78,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,678.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STUDY MANOMETRIC RENAL TB CATH LT,3246261,CDM,361,RC,50396,CPT,5372,APC,,,LT  ,outpatient,facility,,,746,746,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
STUDY MANOMETRIC RENAL TB CATH RT,3246279,CDM,361,RC,50396,CPT,,,,,RT  ,inpatient,facility,,,746,313.32,634.1,716.16,,634.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,649.02,,,percent of total billed charges,,,,,,,,,671.4,,,percent of total billed charges,,,716.16,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,693.78,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
STUDY MANOMETRIC RENAL TB CATH RT,3246279,CDM,361,RC,50396,CPT,,,,,RT  ,outpatient,facility,,,746,313.32,201.42,3522,,634.1,,,percent of total billed charges,,,201.42,,,percent of total billed charges,,,513.25,,,percent of total billed charges,,,502.06,,,percent of total billed charges,,,630.37,,,percent of total billed charges,,,,,,,,,649.02,,,percent of total billed charges,,,649.02,,,percent of total billed charges,,,634.1,,,percent of total billed charges,,,716.16,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,671.4,,,percent of total billed charges,,,,,,,,,693.78,,,percent of total billed charges,,,708.7,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,678.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
STUDY MANOMETRIC RENAL TB CATH RT,3246279,CDM,361,RC,50396,CPT,5372,APC,,,RT  ,outpatient,facility,,,746,746,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ CATH URETERAL BI,3246287,CDM,361,RC,50684,CPT,,,,,50,inpatient,facility,,,781,328.02,663.85,749.76,,663.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,679.47,,,percent of total billed charges,,,,,,,,,702.9,,,percent of total billed charges,,,749.76,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,726.33,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CATH URETERAL BI,3246287,CDM,361,RC,50684,CPT,,,,,50,outpatient,facility,,,781,328.02,210.87,3428,,663.85,,,percent of total billed charges,,,210.87,,,percent of total billed charges,,,537.33,,,percent of total billed charges,,,525.61,,,percent of total billed charges,,,659.94,,,percent of total billed charges,,,,,,,,,679.47,,,percent of total billed charges,,,679.47,,,percent of total billed charges,,,663.85,,,percent of total billed charges,,,749.76,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,702.9,,,percent of total billed charges,,,,,,,,,726.33,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,,,,,,,781,,,fee schedule,,,781,,,fee schedule,,,781,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,710.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ CATH URETERAL LT,3246295,CDM,361,RC,50684,CPT,,,,,LT  ,inpatient,facility,,,521,218.82,442.85,500.16,,442.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.27,,,percent of total billed charges,,,,,,,,,468.9,,,percent of total billed charges,,,500.16,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,484.53,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CATH URETERAL LT,3246295,CDM,361,RC,50684,CPT,,,,,LT  ,outpatient,facility,,,521,218.82,140.67,3428,,442.85,,,percent of total billed charges,,,140.67,,,percent of total billed charges,,,358.45,,,percent of total billed charges,,,350.63,,,percent of total billed charges,,,440.25,,,percent of total billed charges,,,,,,,,,453.27,,,percent of total billed charges,,,453.27,,,percent of total billed charges,,,442.85,,,percent of total billed charges,,,500.16,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,468.9,,,percent of total billed charges,,,,,,,,,484.53,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,521,,,fee schedule,,,521,,,fee schedule,,,521,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,474.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ CATH URETERAL RT,3246303,CDM,361,RC,50684,CPT,,,,,RT  ,inpatient,facility,,,521,218.82,442.85,500.16,,442.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.27,,,percent of total billed charges,,,,,,,,,468.9,,,percent of total billed charges,,,500.16,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,484.53,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ CATH URETERAL RT,3246303,CDM,361,RC,50684,CPT,,,,,RT  ,outpatient,facility,,,521,218.82,140.67,3428,,442.85,,,percent of total billed charges,,,140.67,,,percent of total billed charges,,,358.45,,,percent of total billed charges,,,350.63,,,percent of total billed charges,,,440.25,,,percent of total billed charges,,,,,,,,,453.27,,,percent of total billed charges,,,453.27,,,percent of total billed charges,,,442.85,,,percent of total billed charges,,,500.16,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,468.9,,,percent of total billed charges,,,,,,,,,484.53,,,percent of total billed charges,,,494.95,,,percent of total billed charges,,,,,,,,,,,,,,,521,,,fee schedule,,,521,,,fee schedule,,,521,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,474.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO HIP WO ANES BI,3247038,CDM,361,RC,27093,CPT,,,,,50,inpatient,facility,,,758,318.36,644.3,727.68,,644.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,659.46,,,percent of total billed charges,,,,,,,,,682.2,,,percent of total billed charges,,,727.68,,,percent of total billed charges,,,720.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,704.94,,,percent of total billed charges,,,720.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO HIP WO ANES BI,3247038,CDM,361,RC,27093,CPT,,,,,50,outpatient,facility,,,758,318.36,204.66,3428,,644.3,,,percent of total billed charges,,,204.66,,,percent of total billed charges,,,521.5,,,percent of total billed charges,,,510.13,,,percent of total billed charges,,,640.51,,,percent of total billed charges,,,,,,,,,659.46,,,percent of total billed charges,,,659.46,,,percent of total billed charges,,,644.3,,,percent of total billed charges,,,727.68,,,percent of total billed charges,,,720.1,,,percent of total billed charges,,,,,,,,,682.2,,,percent of total billed charges,,,,,,,,,704.94,,,percent of total billed charges,,,720.1,,,percent of total billed charges,,,,,,,,,,,,,,,758,,,fee schedule,,,758,,,fee schedule,,,758,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,689.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA INIT LT,3247756,CDM,361,RC,37220,CPT,,,,,LT  ,inpatient,facility,,,18434,7742.28,15668.9,17696.64,,15668.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16037.58,,,percent of total billed charges,,,,,,,,,16590.6,,,percent of total billed charges,,,17696.64,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17143.62,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA INIT LT,3247756,CDM,361,RC,37220,CPT,,,,,LT  ,outpatient,facility,,,18434,7742.28,4977.18,28046,,15668.9,,,percent of total billed charges,,,4977.18,,,percent of total billed charges,,,12682.59,,,percent of total billed charges,,,12406.08,,,percent of total billed charges,,,15576.73,,,percent of total billed charges,,,,,,,,,16037.58,,,percent of total billed charges,,,16037.58,,,percent of total billed charges,,,15668.9,,,percent of total billed charges,,,17696.64,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,16590.6,,,percent of total billed charges,,,,,,,,,17143.62,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,16774.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA INIT LT,3247756,CDM,361,RC,37220,CPT,5192,APC,,,LT  ,outpatient,facility,,,18434,18434,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART ILIAC W TLA INIT RT,3247764,CDM,361,RC,37220,CPT,,,,,RT  ,inpatient,facility,,,18434,7742.28,15668.9,17696.64,,15668.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16037.58,,,percent of total billed charges,,,,,,,,,16590.6,,,percent of total billed charges,,,17696.64,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17143.62,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA INIT RT,3247764,CDM,361,RC,37220,CPT,,,,,RT  ,outpatient,facility,,,18434,7742.28,4977.18,28046,,15668.9,,,percent of total billed charges,,,4977.18,,,percent of total billed charges,,,12682.59,,,percent of total billed charges,,,12406.08,,,percent of total billed charges,,,15576.73,,,percent of total billed charges,,,,,,,,,16037.58,,,percent of total billed charges,,,16037.58,,,percent of total billed charges,,,15668.9,,,percent of total billed charges,,,17696.64,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,16590.6,,,percent of total billed charges,,,,,,,,,17143.62,,,percent of total billed charges,,,17512.3,,,percent of total billed charges,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,5715.84,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,16774.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA INIT RT,3247764,CDM,361,RC,37220,CPT,5192,APC,,,RT  ,outpatient,facility,,,18434,18434,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART ILIAC W TLA INIT BI,3247772,CDM,361,RC,37220,CPT,,,,,50,inpatient,facility,,,27651,11613.42,23503.35,26544.96,,23503.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24056.37,,,percent of total billed charges,,,,,,,,,24885.9,,,percent of total billed charges,,,26544.96,,,percent of total billed charges,,,26268.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,25715.43,,,percent of total billed charges,,,26268.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA INIT BI,3247772,CDM,361,RC,37220,CPT,,,,,50,outpatient,facility,,,27651,11613.42,7465.77,28046,,23503.35,,,percent of total billed charges,,,7465.77,,,percent of total billed charges,,,19023.89,,,percent of total billed charges,,,18609.12,,,percent of total billed charges,,,23365.09,,,percent of total billed charges,,,,,,,,,24056.37,,,percent of total billed charges,,,24056.37,,,percent of total billed charges,,,23503.35,,,percent of total billed charges,,,26544.96,,,percent of total billed charges,,,26268.45,,,percent of total billed charges,,,,,,,,,24885.9,,,percent of total billed charges,,,,,,,,,25715.43,,,percent of total billed charges,,,26268.45,,,percent of total billed charges,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,11001.5,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,25162.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA INIT BI,3247772,CDM,361,RC,37220,CPT,5193,APC,,,50,outpatient,facility,,,27651,27651,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART ILIAC W STNT INIT LT,3247780,CDM,361,RC,37221,CPT,,,,,LT  ,inpatient,facility,,,22758,9558.36,19344.3,21847.68,,19344.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19799.46,,,percent of total billed charges,,,,,,,,,20482.2,,,percent of total billed charges,,,21847.68,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21164.94,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT INIT LT,3247780,CDM,361,RC,37221,CPT,,,,,LT  ,outpatient,facility,,,22758,9558.36,6144.66,29580,,19344.3,,,percent of total billed charges,,,6144.66,,,percent of total billed charges,,,15657.5,,,percent of total billed charges,,,15316.13,,,percent of total billed charges,,,19230.51,,,percent of total billed charges,,,,,,,,,19799.46,,,percent of total billed charges,,,19799.46,,,percent of total billed charges,,,19344.3,,,percent of total billed charges,,,21847.68,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,20482.2,,,percent of total billed charges,,,,,,,,,21164.94,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,,,,,,,22758,,,fee schedule,,,22758,,,fee schedule,,,22758,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,20709.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT INIT LT,3247780,CDM,361,RC,37221,CPT,5193,APC,,,LT  ,outpatient,facility,,,22758,22758,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART ILIAC W STNT INIT RT,3247798,CDM,361,RC,37221,CPT,,,,,RT  ,inpatient,facility,,,22758,9558.36,19344.3,21847.68,,19344.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19799.46,,,percent of total billed charges,,,,,,,,,20482.2,,,percent of total billed charges,,,21847.68,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21164.94,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT INIT RT,3247798,CDM,361,RC,37221,CPT,,,,,RT  ,outpatient,facility,,,22758,9558.36,6144.66,29580,,19344.3,,,percent of total billed charges,,,6144.66,,,percent of total billed charges,,,15657.5,,,percent of total billed charges,,,15316.13,,,percent of total billed charges,,,19230.51,,,percent of total billed charges,,,,,,,,,19799.46,,,percent of total billed charges,,,19799.46,,,percent of total billed charges,,,19344.3,,,percent of total billed charges,,,21847.68,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,20482.2,,,percent of total billed charges,,,,,,,,,21164.94,,,percent of total billed charges,,,21620.1,,,percent of total billed charges,,,,,,,,,,,,,,,22758,,,fee schedule,,,22758,,,fee schedule,,,22758,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,20709.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT INIT RT,3247798,CDM,361,RC,37221,CPT,5193,APC,,,RT  ,outpatient,facility,,,22758,22758,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART ILIAC W STNT INIT BI,3247806,CDM,361,RC,37221,CPT,,,,,50,inpatient,facility,,,34137,14337.54,29016.45,32771.52,,29016.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29699.19,,,percent of total billed charges,,,,,,,,,30723.3,,,percent of total billed charges,,,32771.52,,,percent of total billed charges,,,32430.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,31747.41,,,percent of total billed charges,,,32430.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT INIT BI,3247806,CDM,361,RC,37221,CPT,,,,,50,outpatient,facility,,,34137,14337.54,9216.99,34137,,29016.45,,,percent of total billed charges,,,9216.99,,,percent of total billed charges,,,23486.26,,,percent of total billed charges,,,22974.2,,,percent of total billed charges,,,28845.76,,,percent of total billed charges,,,,,,,,,29699.19,,,percent of total billed charges,,,29699.19,,,percent of total billed charges,,,29016.45,,,percent of total billed charges,,,32771.52,,,percent of total billed charges,,,32430.15,,,percent of total billed charges,,,,,,,,,30723.3,,,percent of total billed charges,,,,,,,,,31747.41,,,percent of total billed charges,,,32430.15,,,percent of total billed charges,,,,,,,,,,,,,,,34137,,,fee schedule,,,34137,,,fee schedule,,,34137,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,31064.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT INIT BI,3247806,CDM,361,RC,37221,CPT,5194,APC,,,50,outpatient,facility,,,34137,34137,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART ILIAC W TLA ADDL LT,3247814,CDM,361,RC,37222,CPT,,,,,LT  ,inpatient,facility,,,8648,3632.16,7350.8,8302.08,,7350.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.76,,,percent of total billed charges,,,,,,,,,7783.2,,,percent of total billed charges,,,8302.08,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8042.64,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA ADDL LT,3247814,CDM,361,RC,37222,CPT,,,,,LT  ,outpatient,facility,,,8648,3632.16,2334.96,28046,,7350.8,,,percent of total billed charges,,,2334.96,,,percent of total billed charges,,,5949.82,,,percent of total billed charges,,,5820.1,,,percent of total billed charges,,,7307.56,,,percent of total billed charges,,,,,,,,,7523.76,,,percent of total billed charges,,,7523.76,,,percent of total billed charges,,,7350.8,,,percent of total billed charges,,,8302.08,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,7783.2,,,percent of total billed charges,,,,,,,,,8042.64,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,,,,,,,8648,,,fee schedule,,,8648,,,fee schedule,,,8648,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,7869.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA ADDL RT,3247822,CDM,361,RC,37222,CPT,,,,,RT  ,inpatient,facility,,,8648,3632.16,7350.8,8302.08,,7350.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7523.76,,,percent of total billed charges,,,,,,,,,7783.2,,,percent of total billed charges,,,8302.08,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8042.64,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA ADDL RT,3247822,CDM,361,RC,37222,CPT,,,,,RT  ,outpatient,facility,,,8648,3632.16,2334.96,28046,,7350.8,,,percent of total billed charges,,,2334.96,,,percent of total billed charges,,,5949.82,,,percent of total billed charges,,,5820.1,,,percent of total billed charges,,,7307.56,,,percent of total billed charges,,,,,,,,,7523.76,,,percent of total billed charges,,,7523.76,,,percent of total billed charges,,,7350.8,,,percent of total billed charges,,,8302.08,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,7783.2,,,percent of total billed charges,,,,,,,,,8042.64,,,percent of total billed charges,,,8215.6,,,percent of total billed charges,,,,,,,,,,,,,,,8648,,,fee schedule,,,8648,,,fee schedule,,,8648,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,7869.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA ADDL BI,3247830,CDM,361,RC,37222,CPT,,,,,50,inpatient,facility,,,12972,5448.24,11026.2,12453.12,,11026.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11285.64,,,percent of total billed charges,,,,,,,,,11674.8,,,percent of total billed charges,,,12453.12,,,percent of total billed charges,,,12323.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12063.96,,,percent of total billed charges,,,12323.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W TLA ADDL BI,3247830,CDM,361,RC,37222,CPT,,,,,50,outpatient,facility,,,12972,5448.24,3502.44,28046,,11026.2,,,percent of total billed charges,,,3502.44,,,percent of total billed charges,,,8924.74,,,percent of total billed charges,,,8730.16,,,percent of total billed charges,,,10961.34,,,percent of total billed charges,,,,,,,,,11285.64,,,percent of total billed charges,,,11285.64,,,percent of total billed charges,,,11026.2,,,percent of total billed charges,,,12453.12,,,percent of total billed charges,,,12323.4,,,percent of total billed charges,,,,,,,,,11674.8,,,percent of total billed charges,,,,,,,,,12063.96,,,percent of total billed charges,,,12323.4,,,percent of total billed charges,,,,,,,,,,,,,,,12972,,,fee schedule,,,12972,,,fee schedule,,,12972,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,11804.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT ADDL LT,3247848,CDM,361,RC,37223,CPT,,,,,LT  ,inpatient,facility,,,9786,4110.12,8318.1,9394.56,,8318.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8513.82,,,percent of total billed charges,,,,,,,,,8807.4,,,percent of total billed charges,,,9394.56,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9100.98,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT ADDL LT,3247848,CDM,361,RC,37223,CPT,,,,,LT  ,outpatient,facility,,,9786,4110.12,2642.22,28046,,8318.1,,,percent of total billed charges,,,2642.22,,,percent of total billed charges,,,6732.77,,,percent of total billed charges,,,6585.98,,,percent of total billed charges,,,8269.17,,,percent of total billed charges,,,,,,,,,8513.82,,,percent of total billed charges,,,8513.82,,,percent of total billed charges,,,8318.1,,,percent of total billed charges,,,9394.56,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,8807.4,,,percent of total billed charges,,,,,,,,,9100.98,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,,,,,,,9786,,,fee schedule,,,9786,,,fee schedule,,,9786,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,8905.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT ADDL RT,3247855,CDM,361,RC,37223,CPT,,,,,RT  ,inpatient,facility,,,9786,4110.12,8318.1,9394.56,,8318.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8513.82,,,percent of total billed charges,,,,,,,,,8807.4,,,percent of total billed charges,,,9394.56,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9100.98,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT ADDL RT,3247855,CDM,361,RC,37223,CPT,,,,,RT  ,outpatient,facility,,,9786,4110.12,2642.22,28046,,8318.1,,,percent of total billed charges,,,2642.22,,,percent of total billed charges,,,6732.77,,,percent of total billed charges,,,6585.98,,,percent of total billed charges,,,8269.17,,,percent of total billed charges,,,,,,,,,8513.82,,,percent of total billed charges,,,8513.82,,,percent of total billed charges,,,8318.1,,,percent of total billed charges,,,9394.56,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,8807.4,,,percent of total billed charges,,,,,,,,,9100.98,,,percent of total billed charges,,,9296.7,,,percent of total billed charges,,,,,,,,,,,,,,,9786,,,fee schedule,,,9786,,,fee schedule,,,9786,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,8905.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT ADDL BI,3247863,CDM,361,RC,37223,CPT,,,,,50,inpatient,facility,,,14679,6165.18,12477.15,14091.84,,12477.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12770.73,,,percent of total billed charges,,,,,,,,,13211.1,,,percent of total billed charges,,,14091.84,,,percent of total billed charges,,,13945.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13651.47,,,percent of total billed charges,,,13945.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART ILIAC W STNT ADDL BI,3247863,CDM,361,RC,37223,CPT,,,,,50,outpatient,facility,,,14679,6165.18,3963.33,28046,,12477.15,,,percent of total billed charges,,,3963.33,,,percent of total billed charges,,,10099.15,,,percent of total billed charges,,,9878.97,,,percent of total billed charges,,,12403.75,,,percent of total billed charges,,,,,,,,,12770.73,,,percent of total billed charges,,,12770.73,,,percent of total billed charges,,,12477.15,,,percent of total billed charges,,,14091.84,,,percent of total billed charges,,,13945.05,,,percent of total billed charges,,,,,,,,,13211.1,,,percent of total billed charges,,,,,,,,,13651.47,,,percent of total billed charges,,,13945.05,,,percent of total billed charges,,,,,,,,,,,,,,,14679,,,fee schedule,,,14679,,,fee schedule,,,14679,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,13357.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W TLA LT,3247871,CDM,361,RC,37224,CPT,,,,,LT  ,inpatient,facility,,,25216,10590.72,21433.6,24207.36,,21433.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21937.92,,,percent of total billed charges,,,,,,,,,22694.4,,,percent of total billed charges,,,24207.36,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23450.88,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W TLA LT,3247871,CDM,361,RC,37224,CPT,,,,,LT  ,outpatient,facility,,,25216,10590.72,6808.32,28046,,21433.6,,,percent of total billed charges,,,6808.32,,,percent of total billed charges,,,17348.61,,,percent of total billed charges,,,16970.37,,,percent of total billed charges,,,21307.52,,,percent of total billed charges,,,,,,,,,21937.92,,,percent of total billed charges,,,21937.92,,,percent of total billed charges,,,21433.6,,,percent of total billed charges,,,24207.36,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,22694.4,,,percent of total billed charges,,,,,,,,,23450.88,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,,,,,,,25216,,,fee schedule,,,25216,,,fee schedule,,,25216,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,22946.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W TLA LT,3247871,CDM,361,RC,37224,CPT,5192,APC,,,LT  ,outpatient,facility,,,25216,25216,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W TLA RT,3247889,CDM,361,RC,37224,CPT,,,,,RT  ,inpatient,facility,,,25216,10590.72,21433.6,24207.36,,21433.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21937.92,,,percent of total billed charges,,,,,,,,,22694.4,,,percent of total billed charges,,,24207.36,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23450.88,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W TLA RT,3247889,CDM,361,RC,37224,CPT,,,,,RT  ,outpatient,facility,,,25216,10590.72,6808.32,28046,,21433.6,,,percent of total billed charges,,,6808.32,,,percent of total billed charges,,,17348.61,,,percent of total billed charges,,,16970.37,,,percent of total billed charges,,,21307.52,,,percent of total billed charges,,,,,,,,,21937.92,,,percent of total billed charges,,,21937.92,,,percent of total billed charges,,,21433.6,,,percent of total billed charges,,,24207.36,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,22694.4,,,percent of total billed charges,,,,,,,,,23450.88,,,percent of total billed charges,,,23955.2,,,percent of total billed charges,,,,,,,,,,,,,,,25216,,,fee schedule,,,25216,,,fee schedule,,,25216,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,22946.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W TLA RT,3247889,CDM,361,RC,37224,CPT,5192,APC,,,RT  ,outpatient,facility,,,25216,25216,2833.02,8457.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5949.14,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5832.49,,,fee schedule,,,,,,,,,,,,,,,8457.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7873.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5832.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5832.49,,,fee schedule,,,5832.49,,,fee schedule,,,2833.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W TLA BI,3247897,CDM,361,RC,37224,CPT,,,,,50,inpatient,facility,,,37824,15886.08,32150.4,36311.04,,32150.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,32906.88,,,percent of total billed charges,,,,,,,,,34041.6,,,percent of total billed charges,,,36311.04,,,percent of total billed charges,,,35932.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,35176.32,,,percent of total billed charges,,,35932.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W TLA BI,3247897,CDM,361,RC,37224,CPT,,,,,50,outpatient,facility,,,37824,15886.08,10212.48,37824,,32150.4,,,percent of total billed charges,,,10212.48,,,percent of total billed charges,,,26022.91,,,percent of total billed charges,,,25455.55,,,percent of total billed charges,,,31961.28,,,percent of total billed charges,,,,,,,,,32906.88,,,percent of total billed charges,,,32906.88,,,percent of total billed charges,,,32150.4,,,percent of total billed charges,,,36311.04,,,percent of total billed charges,,,35932.8,,,percent of total billed charges,,,,,,,,,34041.6,,,percent of total billed charges,,,,,,,,,35176.32,,,percent of total billed charges,,,35932.8,,,percent of total billed charges,,,,,,,,,,,,,,,37824,,,fee schedule,,,37824,,,fee schedule,,,37824,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,34419.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W TLA BI,3247897,CDM,361,RC,37224,CPT,5193,APC,,,50,outpatient,facility,,,37824,37824,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W ATHR LT,3247905,CDM,361,RC,37225,CPT,,,,,LT  ,inpatient,facility,,,34413,14453.46,29251.05,33036.48,,29251.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29939.31,,,percent of total billed charges,,,,,,,,,30971.7,,,percent of total billed charges,,,33036.48,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32004.09,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W ATHR LT,3247905,CDM,361,RC,37225,CPT,,,,,LT  ,outpatient,facility,,,34413,14453.46,9291.51,34413,,29251.05,,,percent of total billed charges,,,9291.51,,,percent of total billed charges,,,23676.14,,,percent of total billed charges,,,23159.95,,,percent of total billed charges,,,29078.99,,,percent of total billed charges,,,,,,,,,29939.31,,,percent of total billed charges,,,29939.31,,,percent of total billed charges,,,29251.05,,,percent of total billed charges,,,33036.48,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,30971.7,,,percent of total billed charges,,,,,,,,,32004.09,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,,,,,,,34413,,,fee schedule,,,34413,,,fee schedule,,,34413,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,31315.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W ATHR LT,3247905,CDM,361,RC,37225,CPT,5194,APC,,,LT  ,outpatient,facility,,,34413,34413,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W ATHR RT,3247913,CDM,361,RC,37225,CPT,,,,,RT  ,inpatient,facility,,,34413,14453.46,29251.05,33036.48,,29251.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,29939.31,,,percent of total billed charges,,,,,,,,,30971.7,,,percent of total billed charges,,,33036.48,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32004.09,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W ATHR RT,3247913,CDM,361,RC,37225,CPT,,,,,RT  ,outpatient,facility,,,34413,14453.46,9291.51,34413,,29251.05,,,percent of total billed charges,,,9291.51,,,percent of total billed charges,,,23676.14,,,percent of total billed charges,,,23159.95,,,percent of total billed charges,,,29078.99,,,percent of total billed charges,,,,,,,,,29939.31,,,percent of total billed charges,,,29939.31,,,percent of total billed charges,,,29251.05,,,percent of total billed charges,,,33036.48,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,30971.7,,,percent of total billed charges,,,,,,,,,32004.09,,,percent of total billed charges,,,32692.35,,,percent of total billed charges,,,,,,,,,,,,,,,34413,,,fee schedule,,,34413,,,fee schedule,,,34413,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,31315.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W ATHR RT,3247913,CDM,361,RC,37225,CPT,5194,APC,,,RT  ,outpatient,facility,,,34413,34413,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W ATHR BI,3247921,CDM,361,RC,37225,CPT,,,,,50,inpatient,facility,,,51619,21679.98,43876.15,49554.24,,43876.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,44908.53,,,percent of total billed charges,,,,,,,,,46457.1,,,percent of total billed charges,,,49554.24,,,percent of total billed charges,,,49038.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,48005.67,,,percent of total billed charges,,,49038.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W ATHR BI,3247921,CDM,361,RC,37225,CPT,,,,,50,outpatient,facility,,,51619,21679.98,13937.13,51619,,43876.15,,,percent of total billed charges,,,13937.13,,,percent of total billed charges,,,35513.87,,,percent of total billed charges,,,34739.59,,,percent of total billed charges,,,43618.06,,,percent of total billed charges,,,,,,,,,44908.53,,,percent of total billed charges,,,44908.53,,,percent of total billed charges,,,43876.15,,,percent of total billed charges,,,49554.24,,,percent of total billed charges,,,49038.05,,,percent of total billed charges,,,,,,,,,46457.1,,,percent of total billed charges,,,,,,,,,48005.67,,,percent of total billed charges,,,49038.05,,,percent of total billed charges,,,,,,,,,,,,,,,51619,,,fee schedule,,,51619,,,fee schedule,,,51619,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,46973.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W ATHR BI,3247921,CDM,361,RC,37225,CPT,5194,APC,,,50,outpatient,facility,,,51619,51619,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W STNT LT,3247939,CDM,361,RC,37226,CPT,,,,,LT  ,inpatient,facility,,,29666,12459.72,25216.1,28479.36,,25216.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25809.42,,,percent of total billed charges,,,,,,,,,26699.4,,,percent of total billed charges,,,28479.36,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27589.38,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT LT,3247939,CDM,361,RC,37226,CPT,,,,,LT  ,outpatient,facility,,,29666,12459.72,8009.82,29666,,25216.1,,,percent of total billed charges,,,8009.82,,,percent of total billed charges,,,20410.21,,,percent of total billed charges,,,19965.22,,,percent of total billed charges,,,25067.77,,,percent of total billed charges,,,,,,,,,25809.42,,,percent of total billed charges,,,25809.42,,,percent of total billed charges,,,25216.1,,,percent of total billed charges,,,28479.36,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,26699.4,,,percent of total billed charges,,,,,,,,,27589.38,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,,,,,,,29666,,,fee schedule,,,29666,,,fee schedule,,,29666,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,26996.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT LT,3247939,CDM,361,RC,37226,CPT,5193,APC,,,LT  ,outpatient,facility,,,29666,29666,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W STNT RT,3247947,CDM,361,RC,37226,CPT,,,,,RT  ,inpatient,facility,,,29666,12459.72,25216.1,28479.36,,25216.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,25809.42,,,percent of total billed charges,,,,,,,,,26699.4,,,percent of total billed charges,,,28479.36,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,27589.38,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT RT,3247947,CDM,361,RC,37226,CPT,,,,,RT  ,outpatient,facility,,,29666,12459.72,8009.82,29666,,25216.1,,,percent of total billed charges,,,8009.82,,,percent of total billed charges,,,20410.21,,,percent of total billed charges,,,19965.22,,,percent of total billed charges,,,25067.77,,,percent of total billed charges,,,,,,,,,25809.42,,,percent of total billed charges,,,25809.42,,,percent of total billed charges,,,25216.1,,,percent of total billed charges,,,28479.36,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,26699.4,,,percent of total billed charges,,,,,,,,,27589.38,,,percent of total billed charges,,,28182.7,,,percent of total billed charges,,,,,,,,,,,,,,,29666,,,fee schedule,,,29666,,,fee schedule,,,29666,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,26996.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT RT,3247947,CDM,361,RC,37226,CPT,5193,APC,,,RT  ,outpatient,facility,,,29666,29666,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W STNT BI,3247954,CDM,361,RC,37226,CPT,,,,,50,inpatient,facility,,,44499,18689.58,37824.15,42719.04,,37824.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,38714.13,,,percent of total billed charges,,,,,,,,,40049.1,,,percent of total billed charges,,,42719.04,,,percent of total billed charges,,,42274.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,41384.07,,,percent of total billed charges,,,42274.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT BI,3247954,CDM,361,RC,37226,CPT,,,,,50,outpatient,facility,,,44499,18689.58,12014.73,44499,,37824.15,,,percent of total billed charges,,,12014.73,,,percent of total billed charges,,,30615.31,,,percent of total billed charges,,,29947.83,,,percent of total billed charges,,,37601.65,,,percent of total billed charges,,,,,,,,,38714.13,,,percent of total billed charges,,,38714.13,,,percent of total billed charges,,,37824.15,,,percent of total billed charges,,,42719.04,,,percent of total billed charges,,,42274.05,,,percent of total billed charges,,,,,,,,,40049.1,,,percent of total billed charges,,,,,,,,,41384.07,,,percent of total billed charges,,,42274.05,,,percent of total billed charges,,,,,,,,,,,,,,,44499,,,fee schedule,,,44499,,,fee schedule,,,44499,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,40494.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT BI,3247954,CDM,361,RC,37226,CPT,5194,APC,,,50,outpatient,facility,,,44499,44499,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W STNT ANDATHR LT,3247962,CDM,361,RC,37227,CPT,,,,,LT  ,inpatient,facility,,,41236,17319.12,35050.6,39586.56,,35050.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35875.32,,,percent of total billed charges,,,,,,,,,37112.4,,,percent of total billed charges,,,39586.56,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38349.48,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT ANDATHR LT,3247962,CDM,361,RC,37227,CPT,,,,,LT  ,outpatient,facility,,,41236,17319.12,11133.72,41236,,35050.6,,,percent of total billed charges,,,11133.72,,,percent of total billed charges,,,28370.37,,,percent of total billed charges,,,27751.83,,,percent of total billed charges,,,34844.42,,,percent of total billed charges,,,,,,,,,35875.32,,,percent of total billed charges,,,35875.32,,,percent of total billed charges,,,35050.6,,,percent of total billed charges,,,39586.56,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,37112.4,,,percent of total billed charges,,,,,,,,,38349.48,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,,,,,,,41236,,,fee schedule,,,41236,,,fee schedule,,,41236,,,fee schedule,,,,,,,,,36446,,,percent of total billed charges,,,37524.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT ANDATHR LT,3247962,CDM,361,RC,37227,CPT,5194,APC,,,LT  ,outpatient,facility,,,41236,41236,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W STNT ANDATHR RT,3247970,CDM,361,RC,37227,CPT,,,,,RT  ,inpatient,facility,,,41236,17319.12,35050.6,39586.56,,35050.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,35875.32,,,percent of total billed charges,,,,,,,,,37112.4,,,percent of total billed charges,,,39586.56,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,38349.48,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT ANDATHR RT,3247970,CDM,361,RC,37227,CPT,,,,,RT  ,outpatient,facility,,,41236,17319.12,11133.72,41236,,35050.6,,,percent of total billed charges,,,11133.72,,,percent of total billed charges,,,28370.37,,,percent of total billed charges,,,27751.83,,,percent of total billed charges,,,34844.42,,,percent of total billed charges,,,,,,,,,35875.32,,,percent of total billed charges,,,35875.32,,,percent of total billed charges,,,35050.6,,,percent of total billed charges,,,39586.56,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,37112.4,,,percent of total billed charges,,,,,,,,,38349.48,,,percent of total billed charges,,,39174.2,,,percent of total billed charges,,,,,,,,,,,,,,,41236,,,fee schedule,,,41236,,,fee schedule,,,41236,,,fee schedule,,,,,,,,,36446,,,percent of total billed charges,,,37524.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT ANDATHR RT,3247970,CDM,361,RC,37227,CPT,5194,APC,,,RT  ,outpatient,facility,,,41236,41236,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART FEM POP W STNT ANDATHR BI,3247988,CDM,361,RC,37227,CPT,,,,,50,inpatient,facility,,,61853,25978.26,52575.05,59378.88,,52575.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,53812.11,,,percent of total billed charges,,,,,,,,,55667.7,,,percent of total billed charges,,,59378.88,,,percent of total billed charges,,,58760.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,57523.29,,,percent of total billed charges,,,58760.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT ANDATHR BI,3247988,CDM,361,RC,37227,CPT,,,,,50,outpatient,facility,,,61853,25978.26,16700.31,61853,,52575.05,,,percent of total billed charges,,,16700.31,,,percent of total billed charges,,,42554.86,,,percent of total billed charges,,,41627.07,,,percent of total billed charges,,,52265.78,,,percent of total billed charges,,,,,,,,,53812.11,,,percent of total billed charges,,,53812.11,,,percent of total billed charges,,,52575.05,,,percent of total billed charges,,,59378.88,,,percent of total billed charges,,,58760.35,,,percent of total billed charges,,,,,,,,,55667.7,,,percent of total billed charges,,,,,,,,,57523.29,,,percent of total billed charges,,,58760.35,,,percent of total billed charges,,,,,,,,,,,,,,,61853,,,fee schedule,,,61853,,,fee schedule,,,61853,,,fee schedule,,,,,,,,,36446,,,percent of total billed charges,,,56286.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART FEM POP W STNT ANDATHR BI,3247988,CDM,361,RC,37227,CPT,5194,APC,,,50,outpatient,facility,,,61853,61853,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W TLA INIT LT,3247996,CDM,361,RC,37228,CPT,,,,,LT  ,inpatient,facility,,,16629,6984.18,14134.65,15963.84,,14134.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14467.23,,,percent of total billed charges,,,,,,,,,14966.1,,,percent of total billed charges,,,15963.84,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15464.97,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA INIT LT,3247996,CDM,361,RC,37228,CPT,,,,,LT  ,outpatient,facility,,,16629,6984.18,4489.83,28046,,14134.65,,,percent of total billed charges,,,4489.83,,,percent of total billed charges,,,11440.75,,,percent of total billed charges,,,11191.32,,,percent of total billed charges,,,14051.5,,,percent of total billed charges,,,,,,,,,14467.23,,,percent of total billed charges,,,14467.23,,,percent of total billed charges,,,14134.65,,,percent of total billed charges,,,15963.84,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,14966.1,,,percent of total billed charges,,,,,,,,,15464.97,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,,,,,,,16629,,,fee schedule,,,16629,,,fee schedule,,,16629,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,15132.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA INIT LT,3247996,CDM,361,RC,37228,CPT,5193,APC,,,LT  ,outpatient,facility,,,16629,16629,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W TLA INIT RT,3248002,CDM,361,RC,37228,CPT,,,,,RT  ,inpatient,facility,,,16629,6984.18,14134.65,15963.84,,14134.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,14467.23,,,percent of total billed charges,,,,,,,,,14966.1,,,percent of total billed charges,,,15963.84,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,15464.97,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA INIT RT,3248002,CDM,361,RC,37228,CPT,,,,,RT  ,outpatient,facility,,,16629,6984.18,4489.83,28046,,14134.65,,,percent of total billed charges,,,4489.83,,,percent of total billed charges,,,11440.75,,,percent of total billed charges,,,11191.32,,,percent of total billed charges,,,14051.5,,,percent of total billed charges,,,,,,,,,14467.23,,,percent of total billed charges,,,14467.23,,,percent of total billed charges,,,14134.65,,,percent of total billed charges,,,15963.84,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,14966.1,,,percent of total billed charges,,,,,,,,,15464.97,,,percent of total billed charges,,,15797.55,,,percent of total billed charges,,,,,,,,,,,,,,,16629,,,fee schedule,,,16629,,,fee schedule,,,16629,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,15132.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA INIT RT,3248002,CDM,361,RC,37228,CPT,5193,APC,,,RT  ,outpatient,facility,,,16629,16629,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W TLA INIT BI,3248010,CDM,361,RC,37228,CPT,,,,,50,inpatient,facility,,,24943,10476.06,21201.55,23945.28,,21201.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21700.41,,,percent of total billed charges,,,,,,,,,22448.7,,,percent of total billed charges,,,23945.28,,,percent of total billed charges,,,23695.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,23196.99,,,percent of total billed charges,,,23695.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA INIT BI,3248010,CDM,361,RC,37228,CPT,,,,,50,outpatient,facility,,,24943,10476.06,6734.61,28046,,21201.55,,,percent of total billed charges,,,6734.61,,,percent of total billed charges,,,17160.78,,,percent of total billed charges,,,16786.64,,,percent of total billed charges,,,21076.83,,,percent of total billed charges,,,,,,,,,21700.41,,,percent of total billed charges,,,21700.41,,,percent of total billed charges,,,21201.55,,,percent of total billed charges,,,23945.28,,,percent of total billed charges,,,23695.85,,,percent of total billed charges,,,,,,,,,22448.7,,,percent of total billed charges,,,,,,,,,23196.99,,,percent of total billed charges,,,23695.85,,,percent of total billed charges,,,,,,,,,,,,,,,24943,,,fee schedule,,,24943,,,fee schedule,,,24943,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,22698.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA INIT BI,3248010,CDM,361,RC,37228,CPT,5193,APC,,,50,outpatient,facility,,,24943,24943,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W ATHR INIT LT,3248028,CDM,361,RC,37229,CPT,,,,,LT  ,inpatient,facility,,,21618,9079.56,18375.3,20753.28,,18375.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18807.66,,,percent of total billed charges,,,,,,,,,19456.2,,,percent of total billed charges,,,20753.28,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20104.74,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR INIT LT,3248028,CDM,361,RC,37229,CPT,,,,,LT  ,outpatient,facility,,,21618,9079.56,5836.86,29580,,18375.3,,,percent of total billed charges,,,5836.86,,,percent of total billed charges,,,14873.18,,,percent of total billed charges,,,14548.91,,,percent of total billed charges,,,18267.21,,,percent of total billed charges,,,,,,,,,18807.66,,,percent of total billed charges,,,18807.66,,,percent of total billed charges,,,18375.3,,,percent of total billed charges,,,20753.28,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,19456.2,,,percent of total billed charges,,,,,,,,,20104.74,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,,,,,,,21618,,,fee schedule,,,21618,,,fee schedule,,,21618,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,19672.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR INIT LT,3248028,CDM,361,RC,37229,CPT,5194,APC,,,LT  ,outpatient,facility,,,21618,21618,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W ATHR INIT RT,3248036,CDM,361,RC,37229,CPT,,,,,RT  ,inpatient,facility,,,21618,9079.56,18375.3,20753.28,,18375.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18807.66,,,percent of total billed charges,,,,,,,,,19456.2,,,percent of total billed charges,,,20753.28,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20104.74,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR INIT RT,3248036,CDM,361,RC,37229,CPT,,,,,RT  ,outpatient,facility,,,21618,9079.56,5836.86,29580,,18375.3,,,percent of total billed charges,,,5836.86,,,percent of total billed charges,,,14873.18,,,percent of total billed charges,,,14548.91,,,percent of total billed charges,,,18267.21,,,percent of total billed charges,,,,,,,,,18807.66,,,percent of total billed charges,,,18807.66,,,percent of total billed charges,,,18375.3,,,percent of total billed charges,,,20753.28,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,19456.2,,,percent of total billed charges,,,,,,,,,20104.74,,,percent of total billed charges,,,20537.1,,,percent of total billed charges,,,,,,,,,,,,,,,21618,,,fee schedule,,,21618,,,fee schedule,,,21618,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,19672.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR INIT RT,3248036,CDM,361,RC,37229,CPT,5194,APC,,,RT  ,outpatient,facility,,,21618,21618,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W ATHR INIT BI,3248044,CDM,361,RC,37229,CPT,,,,,50,inpatient,facility,,,32426,13618.92,27562.1,31128.96,,27562.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28210.62,,,percent of total billed charges,,,,,,,,,29183.4,,,percent of total billed charges,,,31128.96,,,percent of total billed charges,,,30804.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30156.18,,,percent of total billed charges,,,30804.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR INIT BI,3248044,CDM,361,RC,37229,CPT,,,,,50,outpatient,facility,,,32426,13618.92,8755.02,32426,,27562.1,,,percent of total billed charges,,,8755.02,,,percent of total billed charges,,,22309.09,,,percent of total billed charges,,,21822.7,,,percent of total billed charges,,,27399.97,,,percent of total billed charges,,,,,,,,,28210.62,,,percent of total billed charges,,,28210.62,,,percent of total billed charges,,,27562.1,,,percent of total billed charges,,,31128.96,,,percent of total billed charges,,,30804.7,,,percent of total billed charges,,,,,,,,,29183.4,,,percent of total billed charges,,,,,,,,,30156.18,,,percent of total billed charges,,,30804.7,,,percent of total billed charges,,,,,,,,,,,,,,,32426,,,fee schedule,,,32426,,,fee schedule,,,32426,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,29507.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR INIT BI,3248044,CDM,361,RC,37229,CPT,5194,APC,,,50,outpatient,facility,,,32426,32426,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W STNT INIT LT,3248051,CDM,361,RC,37230,CPT,,,,,LT  ,inpatient,facility,,,21451,9009.42,18233.35,20592.96,,18233.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18662.37,,,percent of total billed charges,,,,,,,,,19305.9,,,percent of total billed charges,,,20592.96,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19949.43,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT INIT LT,3248051,CDM,361,RC,37230,CPT,,,,,LT  ,outpatient,facility,,,21451,9009.42,5791.77,29580,,18233.35,,,percent of total billed charges,,,5791.77,,,percent of total billed charges,,,14758.29,,,percent of total billed charges,,,14436.52,,,percent of total billed charges,,,18126.1,,,percent of total billed charges,,,,,,,,,18662.37,,,percent of total billed charges,,,18662.37,,,percent of total billed charges,,,18233.35,,,percent of total billed charges,,,20592.96,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,19305.9,,,percent of total billed charges,,,,,,,,,19949.43,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,,,,,,,21451,,,fee schedule,,,21451,,,fee schedule,,,21451,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,19520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT INIT LT,3248051,CDM,361,RC,37230,CPT,5194,APC,,,LT  ,outpatient,facility,,,21451,21451,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W STNT INIT RT,3248069,CDM,361,RC,37230,CPT,,,,,RT  ,inpatient,facility,,,21451,9009.42,18233.35,20592.96,,18233.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18662.37,,,percent of total billed charges,,,,,,,,,19305.9,,,percent of total billed charges,,,20592.96,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,19949.43,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT INIT RT,3248069,CDM,361,RC,37230,CPT,,,,,RT  ,outpatient,facility,,,21451,9009.42,5791.77,29580,,18233.35,,,percent of total billed charges,,,5791.77,,,percent of total billed charges,,,14758.29,,,percent of total billed charges,,,14436.52,,,percent of total billed charges,,,18126.1,,,percent of total billed charges,,,,,,,,,18662.37,,,percent of total billed charges,,,18662.37,,,percent of total billed charges,,,18233.35,,,percent of total billed charges,,,20592.96,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,19305.9,,,percent of total billed charges,,,,,,,,,19949.43,,,percent of total billed charges,,,20378.45,,,percent of total billed charges,,,,,,,,,,,,,,,21451,,,fee schedule,,,21451,,,fee schedule,,,21451,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,19520.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT INIT RT,3248069,CDM,361,RC,37230,CPT,5194,APC,,,RT  ,outpatient,facility,,,21451,21451,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W STNT INIT BI,3248077,CDM,361,RC,37230,CPT,,,,,50,inpatient,facility,,,32177,13514.34,27350.45,30889.92,,27350.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,27993.99,,,percent of total billed charges,,,,,,,,,28959.3,,,percent of total billed charges,,,30889.92,,,percent of total billed charges,,,30568.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,29924.61,,,percent of total billed charges,,,30568.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT INIT BI,3248077,CDM,361,RC,37230,CPT,,,,,50,outpatient,facility,,,32177,13514.34,8687.79,32177,,27350.45,,,percent of total billed charges,,,8687.79,,,percent of total billed charges,,,22137.78,,,percent of total billed charges,,,21655.12,,,percent of total billed charges,,,27189.56,,,percent of total billed charges,,,,,,,,,27993.99,,,percent of total billed charges,,,27993.99,,,percent of total billed charges,,,27350.45,,,percent of total billed charges,,,30889.92,,,percent of total billed charges,,,30568.15,,,percent of total billed charges,,,,,,,,,28959.3,,,percent of total billed charges,,,,,,,,,29924.61,,,percent of total billed charges,,,30568.15,,,percent of total billed charges,,,,,,,,,,,,,,,32177,,,fee schedule,,,32177,,,fee schedule,,,32177,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,29281.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT INIT BI,3248077,CDM,361,RC,37230,CPT,5194,APC,,,50,outpatient,facility,,,32177,32177,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W STNT ANDATHR LT,3248085,CDM,361,RC,37231,CPT,,,,,LT  ,inpatient,facility,,,23281,9778.02,19788.85,22349.76,,19788.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20254.47,,,percent of total billed charges,,,,,,,,,20952.9,,,percent of total billed charges,,,22349.76,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21651.33,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ANDATHR LT,3248085,CDM,361,RC,37231,CPT,,,,,LT  ,outpatient,facility,,,23281,9778.02,6285.87,36446,,19788.85,,,percent of total billed charges,,,6285.87,,,percent of total billed charges,,,16017.33,,,percent of total billed charges,,,15668.11,,,percent of total billed charges,,,19672.44,,,percent of total billed charges,,,,,,,,,20254.47,,,percent of total billed charges,,,20254.47,,,percent of total billed charges,,,19788.85,,,percent of total billed charges,,,22349.76,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,20952.9,,,percent of total billed charges,,,,,,,,,21651.33,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,,,,,,,23281,,,fee schedule,,,23281,,,fee schedule,,,23281,,,fee schedule,,,,,,,,,36446,,,percent of total billed charges,,,21185.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ANDATHR LT,3248085,CDM,361,RC,37231,CPT,5194,APC,,,LT  ,outpatient,facility,,,23281,23281,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W STNT ANDATHR RT,3248093,CDM,361,RC,37231,CPT,,,,,RT  ,inpatient,facility,,,23281,9778.02,19788.85,22349.76,,19788.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,20254.47,,,percent of total billed charges,,,,,,,,,20952.9,,,percent of total billed charges,,,22349.76,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21651.33,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ANDATHR RT,3248093,CDM,361,RC,37231,CPT,,,,,RT  ,outpatient,facility,,,23281,9778.02,6285.87,36446,,19788.85,,,percent of total billed charges,,,6285.87,,,percent of total billed charges,,,16017.33,,,percent of total billed charges,,,15668.11,,,percent of total billed charges,,,19672.44,,,percent of total billed charges,,,,,,,,,20254.47,,,percent of total billed charges,,,20254.47,,,percent of total billed charges,,,19788.85,,,percent of total billed charges,,,22349.76,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,20952.9,,,percent of total billed charges,,,,,,,,,21651.33,,,percent of total billed charges,,,22116.95,,,percent of total billed charges,,,,,,,,,,,,,,,23281,,,fee schedule,,,23281,,,fee schedule,,,23281,,,fee schedule,,,,,,,,,36446,,,percent of total billed charges,,,21185.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ANDATHR RT,3248093,CDM,361,RC,37231,CPT,5194,APC,,,RT  ,outpatient,facility,,,23281,23281,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W STNT ANDATHR BI,3248101,CDM,361,RC,37231,CPT,,,,,50,inpatient,facility,,,34921,14666.82,29682.85,33524.16,,29682.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,30381.27,,,percent of total billed charges,,,,,,,,,31428.9,,,percent of total billed charges,,,33524.16,,,percent of total billed charges,,,33174.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,32476.53,,,percent of total billed charges,,,33174.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ANDATHR BI,3248101,CDM,361,RC,37231,CPT,,,,,50,outpatient,facility,,,34921,14666.82,9428.67,36446,,29682.85,,,percent of total billed charges,,,9428.67,,,percent of total billed charges,,,24025.65,,,percent of total billed charges,,,23501.83,,,percent of total billed charges,,,29508.24,,,percent of total billed charges,,,,,,,,,30381.27,,,percent of total billed charges,,,30381.27,,,percent of total billed charges,,,29682.85,,,percent of total billed charges,,,33524.16,,,percent of total billed charges,,,33174.95,,,percent of total billed charges,,,,,,,,,31428.9,,,percent of total billed charges,,,,,,,,,32476.53,,,percent of total billed charges,,,33174.95,,,percent of total billed charges,,,,,,,,,,,,,,,34921,,,fee schedule,,,34921,,,fee schedule,,,34921,,,fee schedule,,,,,,,,,36446,,,percent of total billed charges,,,31778.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ANDATHR BI,3248101,CDM,361,RC,37231,CPT,5194,APC,,,50,outpatient,facility,,,34921,34921,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REVASC ART TIB PER W TLA ADDL LT,3248119,CDM,361,RC,37232,CPT,,,,,LT  ,inpatient,facility,,,6153,2584.26,5230.05,5906.88,,5230.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5353.11,,,percent of total billed charges,,,,,,,,,5537.7,,,percent of total billed charges,,,5906.88,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5722.29,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA ADDL LT,3248119,CDM,361,RC,37232,CPT,,,,,LT  ,outpatient,facility,,,6153,2584.26,1661.31,28046,,5230.05,,,percent of total billed charges,,,1661.31,,,percent of total billed charges,,,4233.26,,,percent of total billed charges,,,4140.97,,,percent of total billed charges,,,5199.28,,,percent of total billed charges,,,,,,,,,5353.11,,,percent of total billed charges,,,5353.11,,,percent of total billed charges,,,5230.05,,,percent of total billed charges,,,5906.88,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,5537.7,,,percent of total billed charges,,,,,,,,,5722.29,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,,,,,,,6153,,,fee schedule,,,6153,,,fee schedule,,,6153,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,5599.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA ADDL RT,3248127,CDM,361,RC,37232,CPT,,,,,RT  ,inpatient,facility,,,6153,2584.26,5230.05,5906.88,,5230.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5353.11,,,percent of total billed charges,,,,,,,,,5537.7,,,percent of total billed charges,,,5906.88,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5722.29,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA ADDL RT,3248127,CDM,361,RC,37232,CPT,,,,,RT  ,outpatient,facility,,,6153,2584.26,1661.31,28046,,5230.05,,,percent of total billed charges,,,1661.31,,,percent of total billed charges,,,4233.26,,,percent of total billed charges,,,4140.97,,,percent of total billed charges,,,5199.28,,,percent of total billed charges,,,,,,,,,5353.11,,,percent of total billed charges,,,5353.11,,,percent of total billed charges,,,5230.05,,,percent of total billed charges,,,5906.88,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,5537.7,,,percent of total billed charges,,,,,,,,,5722.29,,,percent of total billed charges,,,5845.35,,,percent of total billed charges,,,,,,,,,,,,,,,6153,,,fee schedule,,,6153,,,fee schedule,,,6153,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,5599.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA ADDL BI,3248135,CDM,361,RC,37232,CPT,,,,,50,inpatient,facility,,,9229,3876.18,7844.65,8859.84,,7844.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8029.23,,,percent of total billed charges,,,,,,,,,8306.1,,,percent of total billed charges,,,8859.84,,,percent of total billed charges,,,8767.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8582.97,,,percent of total billed charges,,,8767.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W TLA ADDL BI,3248135,CDM,361,RC,37232,CPT,,,,,50,outpatient,facility,,,9229,3876.18,2491.83,28046,,7844.65,,,percent of total billed charges,,,2491.83,,,percent of total billed charges,,,6349.55,,,percent of total billed charges,,,6211.12,,,percent of total billed charges,,,7798.51,,,percent of total billed charges,,,,,,,,,8029.23,,,percent of total billed charges,,,8029.23,,,percent of total billed charges,,,7844.65,,,percent of total billed charges,,,8859.84,,,percent of total billed charges,,,8767.55,,,percent of total billed charges,,,,,,,,,8306.1,,,percent of total billed charges,,,,,,,,,8582.97,,,percent of total billed charges,,,8767.55,,,percent of total billed charges,,,,,,,,,,,,,,,9229,,,fee schedule,,,9229,,,fee schedule,,,9229,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,8398.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR ADDL LT,3248143,CDM,361,RC,37233,CPT,,,,,LT  ,inpatient,facility,,,9978,4190.76,8481.3,9578.88,,8481.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8680.86,,,percent of total billed charges,,,,,,,,,8980.2,,,percent of total billed charges,,,9578.88,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9279.54,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR ADDL LT,3248143,CDM,361,RC,37233,CPT,,,,,LT  ,outpatient,facility,,,9978,4190.76,2694.06,29580,,8481.3,,,percent of total billed charges,,,2694.06,,,percent of total billed charges,,,6864.86,,,percent of total billed charges,,,6715.19,,,percent of total billed charges,,,8431.41,,,percent of total billed charges,,,,,,,,,8680.86,,,percent of total billed charges,,,8680.86,,,percent of total billed charges,,,8481.3,,,percent of total billed charges,,,9578.88,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,8980.2,,,percent of total billed charges,,,,,,,,,9279.54,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,,,,,,,9978,,,fee schedule,,,9978,,,fee schedule,,,9978,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,9079.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR ADDL RT,3248150,CDM,361,RC,37233,CPT,,,,,RT  ,inpatient,facility,,,9978,4190.76,8481.3,9578.88,,8481.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8680.86,,,percent of total billed charges,,,,,,,,,8980.2,,,percent of total billed charges,,,9578.88,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9279.54,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR ADDL RT,3248150,CDM,361,RC,37233,CPT,,,,,RT  ,outpatient,facility,,,9978,4190.76,2694.06,29580,,8481.3,,,percent of total billed charges,,,2694.06,,,percent of total billed charges,,,6864.86,,,percent of total billed charges,,,6715.19,,,percent of total billed charges,,,8431.41,,,percent of total billed charges,,,,,,,,,8680.86,,,percent of total billed charges,,,8680.86,,,percent of total billed charges,,,8481.3,,,percent of total billed charges,,,9578.88,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,8980.2,,,percent of total billed charges,,,,,,,,,9279.54,,,percent of total billed charges,,,9479.1,,,percent of total billed charges,,,,,,,,,,,,,,,9978,,,fee schedule,,,9978,,,fee schedule,,,9978,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,9079.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR ADDL BI,3248168,CDM,361,RC,37233,CPT,,,,,50,inpatient,facility,,,14966,6285.72,12721.1,14367.36,,12721.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13020.42,,,percent of total billed charges,,,,,,,,,13469.4,,,percent of total billed charges,,,14367.36,,,percent of total billed charges,,,14217.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13918.38,,,percent of total billed charges,,,14217.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W ATHR ADDL BI,3248168,CDM,361,RC,37233,CPT,,,,,50,outpatient,facility,,,14966,6285.72,4040.82,29580,,12721.1,,,percent of total billed charges,,,4040.82,,,percent of total billed charges,,,10296.61,,,percent of total billed charges,,,10072.12,,,percent of total billed charges,,,12646.27,,,percent of total billed charges,,,,,,,,,13020.42,,,percent of total billed charges,,,13020.42,,,percent of total billed charges,,,12721.1,,,percent of total billed charges,,,14367.36,,,percent of total billed charges,,,14217.7,,,percent of total billed charges,,,,,,,,,13469.4,,,percent of total billed charges,,,,,,,,,13918.38,,,percent of total billed charges,,,14217.7,,,percent of total billed charges,,,,,,,,,,,,,,,14966,,,fee schedule,,,14966,,,fee schedule,,,14966,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,13619.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ADDL LT,3248176,CDM,361,RC,37234,CPT,,,,,LT  ,inpatient,facility,,,8814,3701.88,7491.9,8461.44,,7491.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7668.18,,,percent of total billed charges,,,,,,,,,7932.6,,,percent of total billed charges,,,8461.44,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8197.02,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ADDL LT,3248176,CDM,361,RC,37234,CPT,,,,,LT  ,outpatient,facility,,,8814,3701.88,2379.78,28046,,7491.9,,,percent of total billed charges,,,2379.78,,,percent of total billed charges,,,6064.03,,,percent of total billed charges,,,5931.82,,,percent of total billed charges,,,7447.83,,,percent of total billed charges,,,,,,,,,7668.18,,,percent of total billed charges,,,7668.18,,,percent of total billed charges,,,7491.9,,,percent of total billed charges,,,8461.44,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,7932.6,,,percent of total billed charges,,,,,,,,,8197.02,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,,,,,,,8814,,,fee schedule,,,8814,,,fee schedule,,,8814,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,8020.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ADDL RT,3248184,CDM,361,RC,37234,CPT,,,,,RT  ,inpatient,facility,,,8814,3701.88,7491.9,8461.44,,7491.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7668.18,,,percent of total billed charges,,,,,,,,,7932.6,,,percent of total billed charges,,,8461.44,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8197.02,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ADDL RT,3248184,CDM,361,RC,37234,CPT,,,,,RT  ,outpatient,facility,,,8814,3701.88,2379.78,28046,,7491.9,,,percent of total billed charges,,,2379.78,,,percent of total billed charges,,,6064.03,,,percent of total billed charges,,,5931.82,,,percent of total billed charges,,,7447.83,,,percent of total billed charges,,,,,,,,,7668.18,,,percent of total billed charges,,,7668.18,,,percent of total billed charges,,,7491.9,,,percent of total billed charges,,,8461.44,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,7932.6,,,percent of total billed charges,,,,,,,,,8197.02,,,percent of total billed charges,,,8373.3,,,percent of total billed charges,,,,,,,,,,,,,,,8814,,,fee schedule,,,8814,,,fee schedule,,,8814,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,8020.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ADDL BI,3248192,CDM,361,RC,37234,CPT,,,,,50,inpatient,facility,,,13220,5552.4,11237,12691.2,,11237,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11501.4,,,percent of total billed charges,,,,,,,,,11898,,,percent of total billed charges,,,12691.2,,,percent of total billed charges,,,12559,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12294.6,,,percent of total billed charges,,,12559,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER W STNT ADDL BI,3248192,CDM,361,RC,37234,CPT,,,,,50,outpatient,facility,,,13220,5552.4,3569.4,28046,,11237,,,percent of total billed charges,,,3569.4,,,percent of total billed charges,,,9095.36,,,percent of total billed charges,,,8897.06,,,percent of total billed charges,,,11170.9,,,percent of total billed charges,,,,,,,,,11501.4,,,percent of total billed charges,,,11501.4,,,percent of total billed charges,,,11237,,,percent of total billed charges,,,12691.2,,,percent of total billed charges,,,12559,,,percent of total billed charges,,,,,,,,,11898,,,percent of total billed charges,,,,,,,,,12294.6,,,percent of total billed charges,,,12559,,,percent of total billed charges,,,,,,,,,,,,,,,13220,,,fee schedule,,,13220,,,fee schedule,,,13220,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,12030.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER STNT ANDATHR ADD LT,3248200,CDM,361,RC,37235,CPT,,,,,LT  ,inpatient,facility,,,12306,5168.52,10460.1,11813.76,,10460.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10706.22,,,percent of total billed charges,,,,,,,,,11075.4,,,percent of total billed charges,,,11813.76,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11444.58,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER STNT ANDATHR ADD LT,3248200,CDM,361,RC,37235,CPT,,,,,LT  ,outpatient,facility,,,12306,5168.52,3322.62,28046,,10460.1,,,percent of total billed charges,,,3322.62,,,percent of total billed charges,,,8466.53,,,percent of total billed charges,,,8281.94,,,percent of total billed charges,,,10398.57,,,percent of total billed charges,,,,,,,,,10706.22,,,percent of total billed charges,,,10706.22,,,percent of total billed charges,,,10460.1,,,percent of total billed charges,,,11813.76,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,11075.4,,,percent of total billed charges,,,,,,,,,11444.58,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,,,,,,,12306,,,fee schedule,,,12306,,,fee schedule,,,12306,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,11198.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER STNT ANDATHR ADD RT,3248218,CDM,361,RC,37235,CPT,,,,,RT  ,inpatient,facility,,,12306,5168.52,10460.1,11813.76,,10460.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10706.22,,,percent of total billed charges,,,,,,,,,11075.4,,,percent of total billed charges,,,11813.76,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11444.58,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER STNT ANDATHR ADD RT,3248218,CDM,361,RC,37235,CPT,,,,,RT  ,outpatient,facility,,,12306,5168.52,3322.62,28046,,10460.1,,,percent of total billed charges,,,3322.62,,,percent of total billed charges,,,8466.53,,,percent of total billed charges,,,8281.94,,,percent of total billed charges,,,10398.57,,,percent of total billed charges,,,,,,,,,10706.22,,,percent of total billed charges,,,10706.22,,,percent of total billed charges,,,10460.1,,,percent of total billed charges,,,11813.76,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,11075.4,,,percent of total billed charges,,,,,,,,,11444.58,,,percent of total billed charges,,,11690.7,,,percent of total billed charges,,,,,,,,,,,,,,,12306,,,fee schedule,,,12306,,,fee schedule,,,12306,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,11198.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER STNT ANDATHR ADD BI,3248226,CDM,361,RC,37235,CPT,,,,,50,inpatient,facility,,,18458,7752.36,15689.3,17719.68,,15689.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,16058.46,,,percent of total billed charges,,,,,,,,,16612.2,,,percent of total billed charges,,,17719.68,,,percent of total billed charges,,,17535.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,17165.94,,,percent of total billed charges,,,17535.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REVASC ART TIB PER STNT ANDATHR ADD BI,3248226,CDM,361,RC,37235,CPT,,,,,50,outpatient,facility,,,18458,7752.36,4983.66,28046,,15689.3,,,percent of total billed charges,,,4983.66,,,percent of total billed charges,,,12699.1,,,percent of total billed charges,,,12422.23,,,percent of total billed charges,,,15597.01,,,percent of total billed charges,,,,,,,,,16058.46,,,percent of total billed charges,,,16058.46,,,percent of total billed charges,,,15689.3,,,percent of total billed charges,,,17719.68,,,percent of total billed charges,,,17535.1,,,percent of total billed charges,,,,,,,,,16612.2,,,percent of total billed charges,,,,,,,,,17165.94,,,percent of total billed charges,,,17535.1,,,percent of total billed charges,,,,,,,,,,,,,,,18458,,,fee schedule,,,18458,,,fee schedule,,,18458,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,16796.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHOLECYSTOSTOMY PERC W IMG GD S ANDI,3248259,CDM,361,RC,47490,CPT,,,,,,inpatient,facility,,,5427,2279.34,4612.95,5209.92,,4612.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4721.49,,,percent of total billed charges,,,,,,,,,4884.3,,,percent of total billed charges,,,5209.92,,,percent of total billed charges,,,5155.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5047.11,,,percent of total billed charges,,,5155.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHOLECYSTOSTOMY PERC W IMG GD S ANDI,3248259,CDM,361,RC,47490,CPT,,,,,,outpatient,facility,,,5427,2279.34,1465.29,15487,,4612.95,,,percent of total billed charges,,,1465.29,,,percent of total billed charges,,,3733.78,,,percent of total billed charges,,,3652.37,,,percent of total billed charges,,,4585.81,,,percent of total billed charges,,,,,,,,,4721.49,,,percent of total billed charges,,,4721.49,,,percent of total billed charges,,,4612.95,,,percent of total billed charges,,,5209.92,,,percent of total billed charges,,,5155.65,,,percent of total billed charges,,,,,,,,,4884.3,,,percent of total billed charges,,,,,,,,,5047.11,,,percent of total billed charges,,,5155.65,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4938.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHOLECYSTOSTOMY PERC W IMG GD S ANDI,3248259,CDM,361,RC,47490,CPT,5341,APC,,,,outpatient,facility,,,5427,5427,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM CATH INTRAPERIT,3248283,CDM,361,RC,49422,CPT,,,,,,inpatient,facility,,,4570,1919.4,3884.5,4387.2,,3884.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3975.9,,,percent of total billed charges,,,,,,,,,4113,,,percent of total billed charges,,,4387.2,,,percent of total billed charges,,,4341.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4250.1,,,percent of total billed charges,,,4341.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM CATH INTRAPERIT,3248283,CDM,361,RC,49422,CPT,,,,,,outpatient,facility,,,4570,1919.4,1233.9,15487,,3884.5,,,percent of total billed charges,,,1233.9,,,percent of total billed charges,,,3144.16,,,percent of total billed charges,,,3075.61,,,percent of total billed charges,,,3861.65,,,percent of total billed charges,,,,,,,,,3975.9,,,percent of total billed charges,,,3975.9,,,percent of total billed charges,,,3884.5,,,percent of total billed charges,,,4387.2,,,percent of total billed charges,,,4341.5,,,percent of total billed charges,,,,,,,,,4113,,,percent of total billed charges,,,,,,,,,4250.1,,,percent of total billed charges,,,4341.5,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4158.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM CATH INTRAPERIT,3248283,CDM,361,RC,49422,CPT,5183,APC,,,,outpatient,facility,,,4570,4570,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID TRFR C T FL CT GD 1LV BI,3248291,CDM,361,RC,64479,CPT,,,,,50,inpatient,facility,,,3308,1389.36,2811.8,3175.68,,2811.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2877.96,,,percent of total billed charges,,,,,,,,,2977.2,,,percent of total billed charges,,,3175.68,,,percent of total billed charges,,,3142.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3076.44,,,percent of total billed charges,,,3142.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD 1LV BI,3248291,CDM,361,RC,64479,CPT,,,,,50,outpatient,facility,,,3308,1389.36,893.16,3522,,2811.8,,,percent of total billed charges,,,893.16,,,percent of total billed charges,,,2275.9,,,percent of total billed charges,,,2226.28,,,percent of total billed charges,,,2795.26,,,percent of total billed charges,,,,,,,,,2877.96,,,percent of total billed charges,,,2877.96,,,percent of total billed charges,,,2811.8,,,percent of total billed charges,,,3175.68,,,percent of total billed charges,,,3142.6,,,percent of total billed charges,,,,,,,,,2977.2,,,percent of total billed charges,,,,,,,,,3076.44,,,percent of total billed charges,,,3142.6,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,3010.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD 1LV BI,3248291,CDM,361,RC,64479,CPT,5443,APC,,,50,outpatient,facility,,,3308,3308,694.36,2022.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,2022.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1883.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1395.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1395.16,,,fee schedule,,,1395.16,,,fee schedule,,,694.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID TRFR C T FL CT GD 1LV LT,3248309,CDM,361,RC,64479,CPT,,,,,LT  ,inpatient,facility,,,2205,926.1,1874.25,2116.8,,1874.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1918.35,,,percent of total billed charges,,,,,,,,,1984.5,,,percent of total billed charges,,,2116.8,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2050.65,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD 1LV LT,3248309,CDM,361,RC,64479,CPT,,,,,LT  ,outpatient,facility,,,2205,926.1,595.35,3522,,1874.25,,,percent of total billed charges,,,595.35,,,percent of total billed charges,,,1517.04,,,percent of total billed charges,,,1483.96,,,percent of total billed charges,,,1863.22,,,percent of total billed charges,,,,,,,,,1918.35,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,,1874.25,,,percent of total billed charges,,,2116.8,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,1984.5,,,percent of total billed charges,,,,,,,,,2050.65,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2006.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD 1LV LT,3248309,CDM,361,RC,64479,CPT,5443,APC,,,LT  ,outpatient,facility,,,2205,2205,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID TRFR C T FL CT GD 1LV RT,3248317,CDM,361,RC,64479,CPT,,,,,RT  ,inpatient,facility,,,2205,926.1,1874.25,2116.8,,1874.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1918.35,,,percent of total billed charges,,,,,,,,,1984.5,,,percent of total billed charges,,,2116.8,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2050.65,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD 1LV RT,3248317,CDM,361,RC,64479,CPT,,,,,RT  ,outpatient,facility,,,2205,926.1,595.35,3522,,1874.25,,,percent of total billed charges,,,595.35,,,percent of total billed charges,,,1517.04,,,percent of total billed charges,,,1483.96,,,percent of total billed charges,,,1863.22,,,percent of total billed charges,,,,,,,,,1918.35,,,percent of total billed charges,,,1918.35,,,percent of total billed charges,,,1874.25,,,percent of total billed charges,,,2116.8,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,1984.5,,,percent of total billed charges,,,,,,,,,2050.65,,,percent of total billed charges,,,2094.75,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2006.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD 1LV RT,3248317,CDM,361,RC,64479,CPT,5443,APC,,,RT  ,outpatient,facility,,,2205,2205,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID TRFR C T FL CT GD ADD BI,3248325,CDM,361,RC,64480,CPT,,,,,50,inpatient,facility,,,2257,947.94,1918.45,2166.72,,1918.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1963.59,,,percent of total billed charges,,,,,,,,,2031.3,,,percent of total billed charges,,,2166.72,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2099.01,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD ADD BI,3248325,CDM,361,RC,64480,CPT,,,,,50,outpatient,facility,,,2257,947.94,609.39,3428,,1918.45,,,percent of total billed charges,,,609.39,,,percent of total billed charges,,,1552.82,,,percent of total billed charges,,,1518.96,,,percent of total billed charges,,,1907.16,,,percent of total billed charges,,,,,,,,,1963.59,,,percent of total billed charges,,,1963.59,,,percent of total billed charges,,,1918.45,,,percent of total billed charges,,,2166.72,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,2031.3,,,percent of total billed charges,,,,,,,,,2099.01,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,,,,,,,2257,,,fee schedule,,,2257,,,fee schedule,,,2257,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2053.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD ADD LT,3248333,CDM,361,RC,64480,CPT,,,,,LT  ,inpatient,facility,,,1505,632.1,1279.25,1444.8,,1279.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1309.35,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD ADD LT,3248333,CDM,361,RC,64480,CPT,,,,,LT  ,outpatient,facility,,,1505,632.1,406.35,3428,,1279.25,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,,1035.44,,,percent of total billed charges,,,1012.86,,,percent of total billed charges,,,1271.72,,,percent of total billed charges,,,,,,,,,1309.35,,,percent of total billed charges,,,1309.35,,,percent of total billed charges,,,1279.25,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,1505,,,fee schedule,,,1505,,,fee schedule,,,1505,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1369.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD ADD RT,3248341,CDM,361,RC,64480,CPT,,,,,RT  ,inpatient,facility,,,1505,632.1,1279.25,1444.8,,1279.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1309.35,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR C T FL CT GD ADD RT,3248341,CDM,361,RC,64480,CPT,,,,,RT  ,outpatient,facility,,,1505,632.1,406.35,3428,,1279.25,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,,1035.44,,,percent of total billed charges,,,1012.86,,,percent of total billed charges,,,1271.72,,,percent of total billed charges,,,,,,,,,1309.35,,,percent of total billed charges,,,1309.35,,,percent of total billed charges,,,1279.25,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,1505,,,fee schedule,,,1505,,,fee schedule,,,1505,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1369.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD 1LV BI,3248358,CDM,361,RC,64483,CPT,,,,,50,inpatient,facility,,,2257,947.94,1918.45,2166.72,,1918.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1963.59,,,percent of total billed charges,,,,,,,,,2031.3,,,percent of total billed charges,,,2166.72,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2099.01,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD 1LV BI,3248358,CDM,361,RC,64483,CPT,,,,,50,outpatient,facility,,,2257,947.94,609.39,3522,,1918.45,,,percent of total billed charges,,,609.39,,,percent of total billed charges,,,1552.82,,,percent of total billed charges,,,1518.96,,,percent of total billed charges,,,1907.16,,,percent of total billed charges,,,,,,,,,1963.59,,,percent of total billed charges,,,1963.59,,,percent of total billed charges,,,1918.45,,,percent of total billed charges,,,2166.72,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,2031.3,,,percent of total billed charges,,,,,,,,,2099.01,,,percent of total billed charges,,,2144.15,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2053.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD 1LV BI,3248358,CDM,361,RC,64483,CPT,5443,APC,,,50,outpatient,facility,,,2257,2257,694.36,2022.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,2022.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1883.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1395.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1395.16,,,fee schedule,,,1395.16,,,fee schedule,,,694.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID TRFR L S FL CT GD 1LV LT,3248366,CDM,361,RC,64483,CPT,,,,,LT  ,inpatient,facility,,,1505,632.1,1279.25,1444.8,,1279.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1309.35,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD 1LV LT,3248366,CDM,361,RC,64483,CPT,,,,,LT  ,outpatient,facility,,,1505,632.1,406.35,3522,,1279.25,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,,1035.44,,,percent of total billed charges,,,1012.86,,,percent of total billed charges,,,1271.72,,,percent of total billed charges,,,,,,,,,1309.35,,,percent of total billed charges,,,1309.35,,,percent of total billed charges,,,1279.25,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1369.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD 1LV LT,3248366,CDM,361,RC,64483,CPT,5443,APC,,,LT  ,outpatient,facility,,,1505,1505,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID TRFR L S FL CT GD 1LV RT,3248374,CDM,361,RC,64483,CPT,,,,,RT  ,inpatient,facility,,,1505,632.1,1279.25,1444.8,,1279.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1309.35,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD 1LV RT,3248374,CDM,361,RC,64483,CPT,,,,,RT  ,outpatient,facility,,,1505,632.1,406.35,3522,,1279.25,,,percent of total billed charges,,,406.35,,,percent of total billed charges,,,1035.44,,,percent of total billed charges,,,1012.86,,,percent of total billed charges,,,1271.72,,,percent of total billed charges,,,,,,,,,1309.35,,,percent of total billed charges,,,1309.35,,,percent of total billed charges,,,1279.25,,,percent of total billed charges,,,1444.8,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,1354.5,,,percent of total billed charges,,,,,,,,,1399.65,,,percent of total billed charges,,,1429.75,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1369.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD 1LV RT,3248374,CDM,361,RC,64483,CPT,5443,APC,,,RT  ,outpatient,facility,,,1505,1505,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S EPID TRFR L S FL CT GD ADD BI,3248382,CDM,361,RC,64484,CPT,,,,,50,inpatient,facility,,,1061,445.62,901.85,1018.56,,901.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,923.07,,,percent of total billed charges,,,,,,,,,954.9,,,percent of total billed charges,,,1018.56,,,percent of total billed charges,,,1007.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,986.73,,,percent of total billed charges,,,1007.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD ADD BI,3248382,CDM,361,RC,64484,CPT,,,,,50,outpatient,facility,,,1061,445.62,286.47,3428,,901.85,,,percent of total billed charges,,,286.47,,,percent of total billed charges,,,729.97,,,percent of total billed charges,,,714.05,,,percent of total billed charges,,,896.54,,,percent of total billed charges,,,,,,,,,923.07,,,percent of total billed charges,,,923.07,,,percent of total billed charges,,,901.85,,,percent of total billed charges,,,1018.56,,,percent of total billed charges,,,1007.95,,,percent of total billed charges,,,,,,,,,954.9,,,percent of total billed charges,,,,,,,,,986.73,,,percent of total billed charges,,,1007.95,,,percent of total billed charges,,,,,,,,,,,,,,,1061,,,fee schedule,,,1061,,,fee schedule,,,1061,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,965.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD ADD LT,3248390,CDM,361,RC,64484,CPT,,,,,LT  ,inpatient,facility,,,708,297.36,601.8,679.68,,601.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.96,,,percent of total billed charges,,,,,,,,,637.2,,,percent of total billed charges,,,679.68,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,658.44,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD ADD LT,3248390,CDM,361,RC,64484,CPT,,,,,LT  ,outpatient,facility,,,708,297.36,191.16,3428,,601.8,,,percent of total billed charges,,,191.16,,,percent of total billed charges,,,487.1,,,percent of total billed charges,,,476.48,,,percent of total billed charges,,,598.26,,,percent of total billed charges,,,,,,,,,615.96,,,percent of total billed charges,,,615.96,,,percent of total billed charges,,,601.8,,,percent of total billed charges,,,679.68,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,637.2,,,percent of total billed charges,,,,,,,,,658.44,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,,,,,,,708,,,fee schedule,,,708,,,fee schedule,,,708,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,644.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD ADD RT,3248408,CDM,361,RC,64484,CPT,,,,,RT  ,inpatient,facility,,,708,297.36,601.8,679.68,,601.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,615.96,,,percent of total billed charges,,,,,,,,,637.2,,,percent of total billed charges,,,679.68,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,658.44,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S EPID TRFR L S FL CT GD ADD RT,3248408,CDM,361,RC,64484,CPT,,,,,RT  ,outpatient,facility,,,708,297.36,191.16,3428,,601.8,,,percent of total billed charges,,,191.16,,,percent of total billed charges,,,487.1,,,percent of total billed charges,,,476.48,,,percent of total billed charges,,,598.26,,,percent of total billed charges,,,,,,,,,615.96,,,percent of total billed charges,,,615.96,,,percent of total billed charges,,,601.8,,,percent of total billed charges,,,679.68,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,637.2,,,percent of total billed charges,,,,,,,,,658.44,,,percent of total billed charges,,,672.6,,,percent of total billed charges,,,,,,,,,,,,,,,708,,,fee schedule,,,708,,,fee schedule,,,708,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,644.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH ART RENAL W S ANDI,3248432,CDM,361,RC,0234T,CPT,,,,,,inpatient,facility,,,13309,5589.78,11312.65,12776.64,,11312.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11578.83,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH ART RENAL W S ANDI,3248432,CDM,361,RC,0234T,CPT,,,,,,outpatient,facility,,,13309,5589.78,3593.43,29580,,11312.65,,,percent of total billed charges,,,3593.43,,,percent of total billed charges,,,9156.59,,,percent of total billed charges,,,8956.96,,,percent of total billed charges,,,11246.1,,,percent of total billed charges,,,,,,,,,11578.83,,,percent of total billed charges,,,11578.83,,,percent of total billed charges,,,11312.65,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,13309,,,fee schedule,,,13309,,,fee schedule,,,13309,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,12111.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH ART RENAL W S ANDI,3248432,CDM,361,RC,0234T,CPT,5193,APC,,,,outpatient,facility,,,13309,13309,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ATHERECT PERIPH ART VISC W S ANDI,3248440,CDM,361,RC,0235T,CPT,,,,,,inpatient,facility,,,13309,5589.78,11312.65,12776.64,,11312.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11578.83,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH ART VISC W S ANDI,3248440,CDM,361,RC,0235T,CPT,,,,,,outpatient,facility,,,13309,5589.78,3428,13309,,11312.65,,,percent of total billed charges,,,3593.43,,,percent of total billed charges,,,9156.59,,,percent of total billed charges,,,8956.96,,,percent of total billed charges,,,11246.1,,,percent of total billed charges,,,,,,,,,11578.83,,,percent of total billed charges,,,11578.83,,,percent of total billed charges,,,11312.65,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,13309,,,fee schedule,,,13309,,,fee schedule,,,13309,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,12111.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH AORTA ABD W S ANDI,3248457,CDM,361,RC,0236T,CPT,,,,,,inpatient,facility,,,13309,5589.78,11312.65,12776.64,,11312.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11578.83,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH AORTA ABD W S ANDI,3248457,CDM,361,RC,0236T,CPT,,,,,,outpatient,facility,,,13309,5589.78,3593.43,29580,,11312.65,,,percent of total billed charges,,,3593.43,,,percent of total billed charges,,,9156.59,,,percent of total billed charges,,,8956.96,,,percent of total billed charges,,,11246.1,,,percent of total billed charges,,,,,,,,,11578.83,,,percent of total billed charges,,,11578.83,,,percent of total billed charges,,,11312.65,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,13309,,,fee schedule,,,13309,,,fee schedule,,,13309,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,12111.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH AORTA ABD W S ANDI,3248457,CDM,361,RC,0236T,CPT,5193,APC,,,,outpatient,facility,,,13309,13309,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ATHERECT PERIPH TROOM AND BOARDR BRACH W S ANDI,3248465,CDM,361,RC,0237T,CPT,,,,,,inpatient,facility,,,13309,5589.78,11312.65,12776.64,,11312.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11578.83,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH TROOM AND BOARDR BRACH W S ANDI,3248465,CDM,361,RC,0237T,CPT,,,,,,outpatient,facility,,,13309,5589.78,3593.43,29580,,11312.65,,,percent of total billed charges,,,3593.43,,,percent of total billed charges,,,9156.59,,,percent of total billed charges,,,8956.96,,,percent of total billed charges,,,11246.1,,,percent of total billed charges,,,,,,,,,11578.83,,,percent of total billed charges,,,11578.83,,,percent of total billed charges,,,11312.65,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,13309,,,fee schedule,,,13309,,,fee schedule,,,13309,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,12111.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH TROOM AND BOARDR BRACH W S ANDI,3248465,CDM,361,RC,0237T,CPT,5193,APC,,,,outpatient,facility,,,13309,13309,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ATHERECT PERIPH ART ILIAC W S ANDI,3248473,CDM,361,RC,0238T,CPT,,,,,,inpatient,facility,,,13309,5589.78,11312.65,12776.64,,11312.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11578.83,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH ART ILIAC W S ANDI,3248473,CDM,361,RC,0238T,CPT,,,,,,outpatient,facility,,,13309,5589.78,3593.43,29580,,11312.65,,,percent of total billed charges,,,3593.43,,,percent of total billed charges,,,9156.59,,,percent of total billed charges,,,8956.96,,,percent of total billed charges,,,11246.1,,,percent of total billed charges,,,,,,,,,11578.83,,,percent of total billed charges,,,11578.83,,,percent of total billed charges,,,11312.65,,,percent of total billed charges,,,12776.64,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,11978.1,,,percent of total billed charges,,,,,,,,,12377.37,,,percent of total billed charges,,,12643.55,,,percent of total billed charges,,,,,,,,,,,,,,,13309,,,fee schedule,,,13309,,,fee schedule,,,13309,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,12111.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ATHERECT PERIPH ART ILIAC W S ANDI,3248473,CDM,361,RC,0238T,CPT,5194,APC,,,,outpatient,facility,,,13309,13309,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS CATH INTRAPERIT TUN W IMG,3248630,CDM,361,RC,49418,CPT,,,,,,inpatient,facility,,,7608,3195.36,6466.8,7303.68,,6466.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6618.96,,,percent of total billed charges,,,,,,,,,6847.2,,,percent of total billed charges,,,7303.68,,,percent of total billed charges,,,7227.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7075.44,,,percent of total billed charges,,,7227.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS CATH INTRAPERIT TUN W IMG,3248630,CDM,361,RC,49418,CPT,,,,,,outpatient,facility,,,7608,3195.36,2054.16,15487,,6466.8,,,percent of total billed charges,,,2054.16,,,percent of total billed charges,,,5234.3,,,percent of total billed charges,,,5120.18,,,percent of total billed charges,,,6428.76,,,percent of total billed charges,,,,,,,,,6618.96,,,percent of total billed charges,,,6618.96,,,percent of total billed charges,,,6466.8,,,percent of total billed charges,,,7303.68,,,percent of total billed charges,,,7227.6,,,percent of total billed charges,,,,,,,,,6847.2,,,percent of total billed charges,,,,,,,,,7075.44,,,percent of total billed charges,,,7227.6,,,percent of total billed charges,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,3459.77,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6923.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS CATH INTRAPERIT TUN W IMG,3248630,CDM,361,RC,49418,CPT,5341,APC,,,,outpatient,facility,,,7608,7608,1923.98,5119.05,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3600.99,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3530.38,,,fee schedule,,,,,,,,,,,,,,,5119.05,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4766.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3530.38,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3530.38,,,fee schedule,,,3530.38,,,fee schedule,,,1923.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC STENT URETER TRANSURETH LT S ANDI,3248846,CDM,361,RC,50385,CPT,,,,,LT  ,inpatient,facility,,,2741,1151.22,2329.85,2631.36,,2329.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2384.67,,,percent of total billed charges,,,,,,,,,2466.9,,,percent of total billed charges,,,2631.36,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2549.13,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER TRANSURETH LT S ANDI,3248846,CDM,361,RC,50385,CPT,,,,,LT  ,outpatient,facility,,,2741,1151.22,740.07,11510,,2329.85,,,percent of total billed charges,,,740.07,,,percent of total billed charges,,,1885.81,,,percent of total billed charges,,,1844.69,,,percent of total billed charges,,,2316.14,,,percent of total billed charges,,,,,,,,,2384.67,,,percent of total billed charges,,,2384.67,,,percent of total billed charges,,,2329.85,,,percent of total billed charges,,,2631.36,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,2466.9,,,percent of total billed charges,,,,,,,,,2549.13,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2494.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER TRANSURETH LT S ANDI,3248846,CDM,361,RC,50385,CPT,5373,APC,,,LT  ,outpatient,facility,,,2741,2741,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC STENT URETER TRANSURETH RT S ANDI,3248853,CDM,361,RC,50385,CPT,,,,,RT  ,inpatient,facility,,,2741,1151.22,2329.85,2631.36,,2329.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2384.67,,,percent of total billed charges,,,,,,,,,2466.9,,,percent of total billed charges,,,2631.36,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2549.13,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER TRANSURETH RT S ANDI,3248853,CDM,361,RC,50385,CPT,,,,,RT  ,outpatient,facility,,,2741,1151.22,740.07,11510,,2329.85,,,percent of total billed charges,,,740.07,,,percent of total billed charges,,,1885.81,,,percent of total billed charges,,,1844.69,,,percent of total billed charges,,,2316.14,,,percent of total billed charges,,,,,,,,,2384.67,,,percent of total billed charges,,,2384.67,,,percent of total billed charges,,,2329.85,,,percent of total billed charges,,,2631.36,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,2466.9,,,percent of total billed charges,,,,,,,,,2549.13,,,percent of total billed charges,,,2603.95,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2494.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER TRANSURETH RT S ANDI,3248853,CDM,361,RC,50385,CPT,5373,APC,,,RT  ,outpatient,facility,,,2741,2741,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC STENT URETER TRANSURETH BI S ANDI,3248861,CDM,361,RC,50385,CPT,,,,,50,inpatient,facility,,,4112,1727.04,3495.2,3947.52,,3495.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3577.44,,,percent of total billed charges,,,,,,,,,3700.8,,,percent of total billed charges,,,3947.52,,,percent of total billed charges,,,3906.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3824.16,,,percent of total billed charges,,,3906.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER TRANSURETH BI S ANDI,3248861,CDM,361,RC,50385,CPT,,,,,50,outpatient,facility,,,4112,1727.04,1110.24,11510,,3495.2,,,percent of total billed charges,,,1110.24,,,percent of total billed charges,,,2829.06,,,percent of total billed charges,,,2767.38,,,percent of total billed charges,,,3474.64,,,percent of total billed charges,,,,,,,,,3577.44,,,percent of total billed charges,,,3577.44,,,percent of total billed charges,,,3495.2,,,percent of total billed charges,,,3947.52,,,percent of total billed charges,,,3906.4,,,percent of total billed charges,,,,,,,,,3700.8,,,percent of total billed charges,,,,,,,,,3824.16,,,percent of total billed charges,,,3906.4,,,percent of total billed charges,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,3486.26,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3741.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC STENT URETER TRANSURETH BI S ANDI,3248861,CDM,361,RC,50385,CPT,5374,APC,,,50,outpatient,facility,,,4112,4112,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS SHUNT PERITONEAL VENOUS,3248879,CDM,361,RC,49425,CPT,,,,,,inpatient,facility,,,7493,3147.06,6369.05,7193.28,,6369.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6518.91,,,percent of total billed charges,,,,,,,,,6743.7,,,percent of total billed charges,,,7193.28,,,percent of total billed charges,,,7118.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6968.49,,,percent of total billed charges,,,7118.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS SHUNT PERITONEAL VENOUS,3248879,CDM,361,RC,49425,CPT,,,,,,outpatient,facility,,,7493,3147.06,2023.11,7493,,6369.05,,,percent of total billed charges,,,2023.11,,,percent of total billed charges,,,5155.18,,,percent of total billed charges,,,5042.79,,,percent of total billed charges,,,6331.59,,,percent of total billed charges,,,,,,,,,6518.91,,,percent of total billed charges,,,6518.91,,,percent of total billed charges,,,6369.05,,,percent of total billed charges,,,7193.28,,,percent of total billed charges,,,7118.35,,,percent of total billed charges,,,,,,,,,6743.7,,,percent of total billed charges,,,,,,,,,6968.49,,,percent of total billed charges,,,7118.35,,,percent of total billed charges,,,,,,,,,,,,,,,7493,,,fee schedule,,,7493,,,fee schedule,,,7493,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,6818.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE LS CMP W BEND 6 PLUS VW,3249307,CDM,320,RC,72114,CPT,,,,,,inpatient,facility,,,177,74.34,150.45,169.92,,150.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,153.99,,,percent of total billed charges,,,,,,,,,159.3,,,percent of total billed charges,,,169.92,,,percent of total billed charges,,,168.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,164.61,,,percent of total billed charges,,,168.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE LS CMP W BEND 6 PLUS VW,3249307,CDM,320,RC,72114,CPT,,,,,,outpatient,facility,,,177,74.34,47.79,169.92,,150.45,,,percent of total billed charges,,,47.79,,,percent of total billed charges,,,121.78,,,percent of total billed charges,,,119.12,,,percent of total billed charges,,,149.56,,,percent of total billed charges,,,,,,,,,153.99,,,percent of total billed charges,,,153.99,,,percent of total billed charges,,,150.45,,,percent of total billed charges,,,169.92,,,percent of total billed charges,,,168.15,,,percent of total billed charges,,,,,,,,,159.3,,,percent of total billed charges,,,,,,,,,164.61,,,percent of total billed charges,,,168.15,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,138.24,,,percent of total billed charges,,,161.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE LS CMP W BEND 6 PLUS VW,3249307,CDM,320,RC,72114,CPT,5522,APC,,,,outpatient,facility,,,177,177,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE LS BEND 2 3 VW,3249315,CDM,320,RC,72120,CPT,,,,,,inpatient,facility,,,131,55.02,111.35,125.76,,111.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,113.97,,,percent of total billed charges,,,,,,,,,117.9,,,percent of total billed charges,,,125.76,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,121.83,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE LS BEND 2 3 VW,3249315,CDM,320,RC,72120,CPT,,,,,,outpatient,facility,,,131,55.02,35.37,125.76,,111.35,,,percent of total billed charges,,,35.37,,,percent of total billed charges,,,90.13,,,percent of total billed charges,,,88.16,,,percent of total billed charges,,,110.69,,,percent of total billed charges,,,,,,,,,113.97,,,percent of total billed charges,,,113.97,,,percent of total billed charges,,,111.35,,,percent of total billed charges,,,125.76,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,,,,,,,117.9,,,percent of total billed charges,,,,,,,,,121.83,,,percent of total billed charges,,,124.45,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,102.31,,,percent of total billed charges,,,119.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE LS BEND 2 3 VW,3249315,CDM,320,RC,72120,CPT,5522,APC,,,,outpatient,facility,,,131,131,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ JT SI ANES STRD FL CT GD BI,3249414,CDM,361,RC,27096,CPT,,,,,50,inpatient,facility,,,2719,1141.98,2311.15,2610.24,,2311.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365.53,,,percent of total billed charges,,,,,,,,,2447.1,,,percent of total billed charges,,,2610.24,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2528.67,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ JT SI ANES STRD FL CT GD BI,3249414,CDM,361,RC,27096,CPT,,,,,50,outpatient,facility,,,2719,1141.98,288.96,3428,,2311.15,,,percent of total billed charges,,,734.13,,,percent of total billed charges,,,1870.67,,,percent of total billed charges,,,1829.89,,,percent of total billed charges,,,2297.55,,,percent of total billed charges,,,,,,,,,2365.53,,,percent of total billed charges,,,2365.53,,,percent of total billed charges,,,2311.15,,,percent of total billed charges,,,2610.24,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,2447.1,,,percent of total billed charges,,,,,,,,,2528.67,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2474.29,,,percent of total billed charges,,,,,,,,,,,,,,,288.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ JT SI ANES STRD FL CT GD LT,3249422,CDM,361,RC,27096,CPT,,,,,LT  ,inpatient,facility,,,1813,761.46,1541.05,1740.48,,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1577.31,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ JT SI ANES STRD FL CT GD LT,3249422,CDM,361,RC,27096,CPT,,,,,LT  ,outpatient,facility,,,1813,761.46,144.48,3428,,1541.05,,,percent of total billed charges,,,489.51,,,percent of total billed charges,,,1247.34,,,percent of total billed charges,,,1220.15,,,percent of total billed charges,,,1531.98,,,percent of total billed charges,,,,,,,,,1577.31,,,percent of total billed charges,,,1577.31,,,percent of total billed charges,,,1541.05,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1649.83,,,percent of total billed charges,,,,,,,,,,,,,,,144.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ JT SI ANES STRD FL CT GD RT,3249430,CDM,361,RC,27096,CPT,,,,,RT  ,inpatient,facility,,,1813,761.46,1541.05,1740.48,,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1577.31,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ JT SI ANES STRD FL CT GD RT,3249430,CDM,361,RC,27096,CPT,,,,,RT  ,outpatient,facility,,,1813,761.46,144.48,3428,,1541.05,,,percent of total billed charges,,,489.51,,,percent of total billed charges,,,1247.34,,,percent of total billed charges,,,1220.15,,,percent of total billed charges,,,1531.98,,,percent of total billed charges,,,,,,,,,1577.31,,,percent of total billed charges,,,1577.31,,,percent of total billed charges,,,1541.05,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1649.83,,,percent of total billed charges,,,,,,,,,,,,,,,144.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ JT SI ARTHO FL CT GD BI,3249448,CDM,361,RC,27096,CPT,,,,,50,inpatient,facility,,,2719,1141.98,2311.15,2610.24,,2311.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2365.53,,,percent of total billed charges,,,,,,,,,2447.1,,,percent of total billed charges,,,2610.24,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2528.67,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ JT SI ARTHO FL CT GD BI,3249448,CDM,361,RC,27096,CPT,,,,,50,outpatient,facility,,,2719,1141.98,288.96,3428,,2311.15,,,percent of total billed charges,,,734.13,,,percent of total billed charges,,,1870.67,,,percent of total billed charges,,,1829.89,,,percent of total billed charges,,,2297.55,,,percent of total billed charges,,,,,,,,,2365.53,,,percent of total billed charges,,,2365.53,,,percent of total billed charges,,,2311.15,,,percent of total billed charges,,,2610.24,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,2447.1,,,percent of total billed charges,,,,,,,,,2528.67,,,percent of total billed charges,,,2583.05,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2474.29,,,percent of total billed charges,,,,,,,,,,,,,,,288.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ JT SI ARTHO FL CT GD LT,3249455,CDM,361,RC,27096,CPT,,,,,LT  ,inpatient,facility,,,1813,761.46,1541.05,1740.48,,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1577.31,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ JT SI ARTHO FL CT GD LT,3249455,CDM,361,RC,27096,CPT,,,,,LT  ,outpatient,facility,,,1813,761.46,144.48,3428,,1541.05,,,percent of total billed charges,,,489.51,,,percent of total billed charges,,,1247.34,,,percent of total billed charges,,,1220.15,,,percent of total billed charges,,,1531.98,,,percent of total billed charges,,,,,,,,,1577.31,,,percent of total billed charges,,,1577.31,,,percent of total billed charges,,,1541.05,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1649.83,,,percent of total billed charges,,,,,,,,,,,,,,,144.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ JT SI ARTHO FL CT GD RT,3249463,CDM,361,RC,27096,CPT,,,,,RT  ,inpatient,facility,,,1813,761.46,1541.05,1740.48,,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1577.31,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ JT SI ARTHO FL CT GD RT,3249463,CDM,361,RC,27096,CPT,,,,,RT  ,outpatient,facility,,,1813,761.46,144.48,3428,,1541.05,,,percent of total billed charges,,,489.51,,,percent of total billed charges,,,1247.34,,,percent of total billed charges,,,1220.15,,,percent of total billed charges,,,1531.98,,,percent of total billed charges,,,,,,,,,1577.31,,,percent of total billed charges,,,1577.31,,,percent of total billed charges,,,1541.05,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1649.83,,,percent of total billed charges,,,,,,,,,,,,,,,144.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL 1ST ART RENAL UNI S ANDI,3249471,CDM,361,RC,36251,CPT,,,,,,inpatient,facility,,,6023,2529.66,5119.55,5782.08,,5119.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5240.01,,,percent of total billed charges,,,,,,,,,5420.7,,,percent of total billed charges,,,5782.08,,,percent of total billed charges,,,5721.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5601.39,,,percent of total billed charges,,,5721.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 1ST ART RENAL UNI S ANDI,3249471,CDM,361,RC,36251,CPT,,,,,,outpatient,facility,,,6023,2529.66,1626.21,15487,,5119.55,,,percent of total billed charges,,,1626.21,,,percent of total billed charges,,,4143.82,,,percent of total billed charges,,,4053.48,,,percent of total billed charges,,,5089.43,,,percent of total billed charges,,,,,,,,,5240.01,,,percent of total billed charges,,,5240.01,,,percent of total billed charges,,,5119.55,,,percent of total billed charges,,,5782.08,,,percent of total billed charges,,,5721.85,,,percent of total billed charges,,,,,,,,,5420.7,,,percent of total billed charges,,,,,,,,,5601.39,,,percent of total billed charges,,,5721.85,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,5480.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 1ST ART RENAL UNI S ANDI,3249471,CDM,361,RC,36251,CPT,5183,APC,,,,outpatient,facility,,,6023,6023,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL 1ST ART RENAL BI S ANDI,3249489,CDM,361,RC,36252,CPT,,,,,,inpatient,facility,,,12547,5269.74,10664.95,12045.12,,10664.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10915.89,,,percent of total billed charges,,,,,,,,,11292.3,,,percent of total billed charges,,,12045.12,,,percent of total billed charges,,,11919.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11668.71,,,percent of total billed charges,,,11919.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 1ST ART RENAL BI S ANDI,3249489,CDM,361,RC,36252,CPT,,,,,,outpatient,facility,,,12547,5269.74,3187.59,15487,,10664.95,,,percent of total billed charges,,,3387.69,,,percent of total billed charges,,,8632.34,,,percent of total billed charges,,,8444.13,,,percent of total billed charges,,,10602.22,,,percent of total billed charges,,,,,,,,,10915.89,,,percent of total billed charges,,,10915.89,,,percent of total billed charges,,,10664.95,,,percent of total billed charges,,,12045.12,,,percent of total billed charges,,,11919.65,,,percent of total billed charges,,,,,,,,,11292.3,,,percent of total billed charges,,,,,,,,,11668.71,,,percent of total billed charges,,,11919.65,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,11417.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 1ST ART RENAL BI S ANDI,3249489,CDM,361,RC,36252,CPT,5183,APC,,,,outpatient,facility,,,12547,12547,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL 2ND PLUS ART RENAL UNI S ANDI,3249497,CDM,361,RC,36253,CPT,,,,,,inpatient,facility,,,8365,3513.3,7110.25,8030.4,,7110.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7277.55,,,percent of total billed charges,,,,,,,,,7528.5,,,percent of total billed charges,,,8030.4,,,percent of total billed charges,,,7946.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7779.45,,,percent of total billed charges,,,7946.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 2ND PLUS ART RENAL UNI S ANDI,3249497,CDM,361,RC,36253,CPT,,,,,,outpatient,facility,,,8365,3513.3,2258.55,28046,,7110.25,,,percent of total billed charges,,,2258.55,,,percent of total billed charges,,,5755.12,,,percent of total billed charges,,,5629.64,,,percent of total billed charges,,,7068.43,,,percent of total billed charges,,,,,,,,,7277.55,,,percent of total billed charges,,,7277.55,,,percent of total billed charges,,,7110.25,,,percent of total billed charges,,,8030.4,,,percent of total billed charges,,,7946.75,,,percent of total billed charges,,,,,,,,,7528.5,,,percent of total billed charges,,,,,,,,,7779.45,,,percent of total billed charges,,,7946.75,,,percent of total billed charges,,,,,,,,,,,,,,,8365,,,fee schedule,,,8365,,,fee schedule,,,8365,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,7612.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 2ND PLUS ART RENAL UNI S ANDI,3249497,CDM,361,RC,36253,CPT,5184,APC,,,,outpatient,facility,,,8365,8365,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL 2ND PLUS ART RENAL BI S ANDI,3249505,CDM,361,RC,36254,CPT,,,,,,inpatient,facility,,,14554,6112.68,12370.9,13971.84,,12370.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12661.98,,,percent of total billed charges,,,,,,,,,13098.6,,,percent of total billed charges,,,13971.84,,,percent of total billed charges,,,13826.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13535.22,,,percent of total billed charges,,,13826.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 2ND PLUS ART RENAL BI S ANDI,3249505,CDM,361,RC,36254,CPT,,,,,,outpatient,facility,,,14554,6112.68,3187.59,15487,,12370.9,,,percent of total billed charges,,,3929.58,,,percent of total billed charges,,,10013.15,,,percent of total billed charges,,,9794.84,,,percent of total billed charges,,,12298.13,,,percent of total billed charges,,,,,,,,,12661.98,,,percent of total billed charges,,,12661.98,,,percent of total billed charges,,,12370.9,,,percent of total billed charges,,,13971.84,,,percent of total billed charges,,,13826.3,,,percent of total billed charges,,,,,,,,,13098.6,,,percent of total billed charges,,,,,,,,,13535.22,,,percent of total billed charges,,,13826.3,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,13244.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL 2ND PLUS ART RENAL BI S ANDI,3249505,CDM,361,RC,36254,CPT,5183,APC,,,,outpatient,facility,,,14554,14554,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS FILTER VENA CAVA ENDV S ANDI,3249513,CDM,361,RC,37191,CPT,,,,,,inpatient,facility,,,6213,2609.46,5281.05,5964.48,,5281.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5405.31,,,percent of total billed charges,,,,,,,,,5591.7,,,percent of total billed charges,,,5964.48,,,percent of total billed charges,,,5902.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5778.09,,,percent of total billed charges,,,5902.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS FILTER VENA CAVA ENDV S ANDI,3249513,CDM,361,RC,37191,CPT,,,,,,outpatient,facility,,,6213,2609.46,1677.51,28046,,5281.05,,,percent of total billed charges,,,1677.51,,,percent of total billed charges,,,4274.54,,,percent of total billed charges,,,4181.35,,,percent of total billed charges,,,5249.98,,,percent of total billed charges,,,,,,,,,5405.31,,,percent of total billed charges,,,5405.31,,,percent of total billed charges,,,5281.05,,,percent of total billed charges,,,5964.48,,,percent of total billed charges,,,5902.35,,,percent of total billed charges,,,,,,,,,5591.7,,,percent of total billed charges,,,,,,,,,5778.09,,,percent of total billed charges,,,5902.35,,,percent of total billed charges,,,,,,,,,,,,,,,6213,,,fee schedule,,,6213,,,fee schedule,,,6213,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,5653.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS FILTER VENA CAVA ENDV S ANDI,3249513,CDM,361,RC,37191,CPT,5184,APC,,,,outpatient,facility,,,6213,6213,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REPOS FILTER VENA CAVA ENDV S ANDI,3249521,CDM,361,RC,37192,CPT,,,,,,inpatient,facility,,,9416,3954.72,8003.6,9039.36,,8003.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8191.92,,,percent of total billed charges,,,,,,,,,8474.4,,,percent of total billed charges,,,9039.36,,,percent of total billed charges,,,8945.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8756.88,,,percent of total billed charges,,,8945.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REPOS FILTER VENA CAVA ENDV S ANDI,3249521,CDM,361,RC,37192,CPT,,,,,,outpatient,facility,,,9416,3954.72,2542.32,15487,,8003.6,,,percent of total billed charges,,,2542.32,,,percent of total billed charges,,,6478.21,,,percent of total billed charges,,,6336.97,,,percent of total billed charges,,,7956.52,,,percent of total billed charges,,,,,,,,,8191.92,,,percent of total billed charges,,,8191.92,,,percent of total billed charges,,,8003.6,,,percent of total billed charges,,,9039.36,,,percent of total billed charges,,,8945.2,,,percent of total billed charges,,,,,,,,,8474.4,,,percent of total billed charges,,,,,,,,,8756.88,,,percent of total billed charges,,,8945.2,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,8568.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REPOS FILTER VENA CAVA ENDV S ANDI,3249521,CDM,361,RC,37192,CPT,5183,APC,,,,outpatient,facility,,,9416,9416,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM FILTER VENA CAVA ENDV S ANDI,3249539,CDM,361,RC,37193,CPT,,,,,,inpatient,facility,,,9707,4076.94,8250.95,9318.72,,8250.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8445.09,,,percent of total billed charges,,,,,,,,,8736.3,,,percent of total billed charges,,,9318.72,,,percent of total billed charges,,,9221.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9027.51,,,percent of total billed charges,,,9221.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM FILTER VENA CAVA ENDV S ANDI,3249539,CDM,361,RC,37193,CPT,,,,,,outpatient,facility,,,9707,4076.94,2620.89,15487,,8250.95,,,percent of total billed charges,,,2620.89,,,percent of total billed charges,,,6678.42,,,percent of total billed charges,,,6532.81,,,percent of total billed charges,,,8202.41,,,percent of total billed charges,,,,,,,,,8445.09,,,percent of total billed charges,,,8445.09,,,percent of total billed charges,,,8250.95,,,percent of total billed charges,,,9318.72,,,percent of total billed charges,,,9221.65,,,percent of total billed charges,,,,,,,,,8736.3,,,percent of total billed charges,,,,,,,,,9027.51,,,percent of total billed charges,,,9221.65,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,8833.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM FILTER VENA CAVA ENDV S ANDI,3249539,CDM,361,RC,37193,CPT,5183,APC,,,,outpatient,facility,,,9707,9707,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PARACENTESIS ABDOMINAL WO IMG,3249554,CDM,361,RC,49082,CPT,,,,,,inpatient,facility,,,1343,564.06,1141.55,1289.28,,1141.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1168.41,,,percent of total billed charges,,,,,,,,,1208.7,,,percent of total billed charges,,,1289.28,,,percent of total billed charges,,,1275.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1248.99,,,percent of total billed charges,,,1275.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PARACENTESIS ABDOMINAL WO IMG,3249554,CDM,361,RC,49082,CPT,,,,,,outpatient,facility,,,1343,564.06,362.61,5933,,1141.55,,,percent of total billed charges,,,362.61,,,percent of total billed charges,,,923.98,,,percent of total billed charges,,,903.84,,,percent of total billed charges,,,1134.84,,,percent of total billed charges,,,,,,,,,1168.41,,,percent of total billed charges,,,1168.41,,,percent of total billed charges,,,1141.55,,,percent of total billed charges,,,1289.28,,,percent of total billed charges,,,1275.85,,,percent of total billed charges,,,,,,,,,1208.7,,,percent of total billed charges,,,,,,,,,1248.99,,,percent of total billed charges,,,1275.85,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1222.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PARACENTESIS ABDOMINAL WO IMG,3249554,CDM,361,RC,49082,CPT,5301,APC,,,,outpatient,facility,,,1343,1343,448.42,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,448.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PARACENTESIS ABDOMINAL W IMG,3249562,CDM,361,RC,49083,CPT,,,,,,inpatient,facility,,,1975,829.5,1678.75,1896,,1678.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1718.25,,,percent of total billed charges,,,,,,,,,1777.5,,,percent of total billed charges,,,1896,,,percent of total billed charges,,,1876.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1836.75,,,percent of total billed charges,,,1876.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PARACENTESIS ABDOMINAL W IMG,3249562,CDM,361,RC,49083,CPT,,,,,,outpatient,facility,,,1975,829.5,533.25,5933,,1678.75,,,percent of total billed charges,,,533.25,,,percent of total billed charges,,,1358.8,,,percent of total billed charges,,,1329.17,,,percent of total billed charges,,,1668.88,,,percent of total billed charges,,,,,,,,,1718.25,,,percent of total billed charges,,,1718.25,,,percent of total billed charges,,,1678.75,,,percent of total billed charges,,,1896,,,percent of total billed charges,,,1876.25,,,percent of total billed charges,,,,,,,,,1777.5,,,percent of total billed charges,,,,,,,,,1836.75,,,percent of total billed charges,,,1876.25,,,percent of total billed charges,,,,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,906.51,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1797.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PARACENTESIS ABDOMINAL W IMG,3249562,CDM,361,RC,49083,CPT,5301,APC,,,,outpatient,facility,,,1975,1975,448.42,1341.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,943.51,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,925.01,,,fee schedule,,,,,,,,,,,,,,,1341.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1248.76,,,fee schedule,,,,,,,,,,,,,,,,,,,,,925.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,925.01,,,fee schedule,,,925.01,,,fee schedule,,,448.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DST NRV LUMB SAC FL CT GD SGL BI,3249687,CDM,361,RC,64635,CPT,,,,,50,inpatient,facility,,,3696,1552.32,3141.6,3548.16,,3141.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3215.52,,,percent of total billed charges,,,,,,,,,3326.4,,,percent of total billed charges,,,3548.16,,,percent of total billed charges,,,3511.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3437.28,,,percent of total billed charges,,,3511.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD SGL BI,3249687,CDM,361,RC,64635,CPT,,,,,50,outpatient,facility,,,3696,1552.32,997.92,11510,,3141.6,,,percent of total billed charges,,,997.92,,,percent of total billed charges,,,2542.85,,,percent of total billed charges,,,2487.41,,,percent of total billed charges,,,3123.12,,,percent of total billed charges,,,,,,,,,3215.52,,,percent of total billed charges,,,3215.52,,,percent of total billed charges,,,3141.6,,,percent of total billed charges,,,3548.16,,,percent of total billed charges,,,3511.2,,,percent of total billed charges,,,,,,,,,3326.4,,,percent of total billed charges,,,,,,,,,3437.28,,,percent of total billed charges,,,3511.2,,,percent of total billed charges,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,1930.84,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3363.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD SGL BI,3249687,CDM,361,RC,64635,CPT,5431,APC,,,50,outpatient,facility,,,3696,3696,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DST NRV LUMB SAC FL CT GD SGL LT,3249695,CDM,361,RC,64635,CPT,,,,,LT  ,inpatient,facility,,,2464,1034.88,2094.4,2365.44,,2094.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2143.68,,,percent of total billed charges,,,,,,,,,2217.6,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2291.52,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD SGL LT,3249695,CDM,361,RC,64635,CPT,,,,,LT  ,outpatient,facility,,,2464,1034.88,665.28,11510,,2094.4,,,percent of total billed charges,,,665.28,,,percent of total billed charges,,,1695.23,,,percent of total billed charges,,,1658.27,,,percent of total billed charges,,,2082.08,,,percent of total billed charges,,,,,,,,,2143.68,,,percent of total billed charges,,,2143.68,,,percent of total billed charges,,,2094.4,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,2217.6,,,percent of total billed charges,,,,,,,,,2291.52,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,1930.84,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2242.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD SGL LT,3249695,CDM,361,RC,64635,CPT,5431,APC,,,LT  ,outpatient,facility,,,2464,2464,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DST NRV LUMB SAC FL CT GD SGL RT,3249703,CDM,361,RC,64635,CPT,,,,,RT  ,inpatient,facility,,,2464,1034.88,2094.4,2365.44,,2094.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2143.68,,,percent of total billed charges,,,,,,,,,2217.6,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2291.52,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD SGL RT,3249703,CDM,361,RC,64635,CPT,,,,,RT  ,outpatient,facility,,,2464,1034.88,665.28,11510,,2094.4,,,percent of total billed charges,,,665.28,,,percent of total billed charges,,,1695.23,,,percent of total billed charges,,,1658.27,,,percent of total billed charges,,,2082.08,,,percent of total billed charges,,,,,,,,,2143.68,,,percent of total billed charges,,,2143.68,,,percent of total billed charges,,,2094.4,,,percent of total billed charges,,,2365.44,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,2217.6,,,percent of total billed charges,,,,,,,,,2291.52,,,percent of total billed charges,,,2340.8,,,percent of total billed charges,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,1930.84,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2242.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD SGL RT,3249703,CDM,361,RC,64635,CPT,5431,APC,,,RT  ,outpatient,facility,,,2464,2464,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DST NRV LUMB SAC FL CT GD ADDL BI,3249711,CDM,361,RC,64636,CPT,,,,,50,inpatient,facility,,,998,419.16,848.3,958.08,,848.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,868.26,,,percent of total billed charges,,,,,,,,,898.2,,,percent of total billed charges,,,958.08,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,928.14,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD ADDL BI,3249711,CDM,361,RC,64636,CPT,,,,,50,outpatient,facility,,,998,419.16,269.46,3428,,848.3,,,percent of total billed charges,,,269.46,,,percent of total billed charges,,,686.62,,,percent of total billed charges,,,671.65,,,percent of total billed charges,,,843.31,,,percent of total billed charges,,,,,,,,,868.26,,,percent of total billed charges,,,868.26,,,percent of total billed charges,,,848.3,,,percent of total billed charges,,,958.08,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,898.2,,,percent of total billed charges,,,,,,,,,928.14,,,percent of total billed charges,,,948.1,,,percent of total billed charges,,,,,,,,,,,,,,,998,,,fee schedule,,,998,,,fee schedule,,,998,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,908.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD ADDL LT,3249729,CDM,361,RC,64636,CPT,,,,,LT  ,inpatient,facility,,,666,279.72,566.1,639.36,,566.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,579.42,,,percent of total billed charges,,,,,,,,,599.4,,,percent of total billed charges,,,639.36,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,619.38,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD ADDL LT,3249729,CDM,361,RC,64636,CPT,,,,,LT  ,outpatient,facility,,,666,279.72,179.82,3428,,566.1,,,percent of total billed charges,,,179.82,,,percent of total billed charges,,,458.21,,,percent of total billed charges,,,448.22,,,percent of total billed charges,,,562.77,,,percent of total billed charges,,,,,,,,,579.42,,,percent of total billed charges,,,579.42,,,percent of total billed charges,,,566.1,,,percent of total billed charges,,,639.36,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,599.4,,,percent of total billed charges,,,,,,,,,619.38,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,,,,,,,666,,,fee schedule,,,666,,,fee schedule,,,666,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,606.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD ADDL RT,3249737,CDM,361,RC,64636,CPT,,,,,RT  ,inpatient,facility,,,666,279.72,566.1,639.36,,566.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,579.42,,,percent of total billed charges,,,,,,,,,599.4,,,percent of total billed charges,,,639.36,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,619.38,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV LUMB SAC FL CT GD ADDL RT,3249737,CDM,361,RC,64636,CPT,,,,,RT  ,outpatient,facility,,,666,279.72,179.82,3428,,566.1,,,percent of total billed charges,,,179.82,,,percent of total billed charges,,,458.21,,,percent of total billed charges,,,448.22,,,percent of total billed charges,,,562.77,,,percent of total billed charges,,,,,,,,,579.42,,,percent of total billed charges,,,579.42,,,percent of total billed charges,,,566.1,,,percent of total billed charges,,,639.36,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,599.4,,,percent of total billed charges,,,,,,,,,619.38,,,percent of total billed charges,,,632.7,,,percent of total billed charges,,,,,,,,,,,,,,,666,,,fee schedule,,,666,,,fee schedule,,,666,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,606.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX RENAL TROCAR NDL PERC LT,3249760,CDM,361,RC,50200,CPT,,,,,LT  ,inpatient,facility,,,1814,761.88,1541.9,1741.44,,1541.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1578.18,,,percent of total billed charges,,,,,,,,,1632.6,,,percent of total billed charges,,,1741.44,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1687.02,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX RENAL TROCAR NDL PERC LT,3249760,CDM,361,RC,50200,CPT,,,,,LT  ,outpatient,facility,,,1814,761.88,489.78,5933,,1541.9,,,percent of total billed charges,,,489.78,,,percent of total billed charges,,,1248.03,,,percent of total billed charges,,,1220.82,,,percent of total billed charges,,,1532.83,,,percent of total billed charges,,,,,,,,,1578.18,,,percent of total billed charges,,,1578.18,,,percent of total billed charges,,,1541.9,,,percent of total billed charges,,,1741.44,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,1632.6,,,percent of total billed charges,,,,,,,,,1687.02,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1650.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX RENAL TROCAR NDL PERC LT,3249760,CDM,361,RC,50200,CPT,5072,APC,,,LT  ,outpatient,facility,,,1814,1814,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX RENAL TROCAR NDL PERC RT,3249778,CDM,361,RC,50200,CPT,,,,,RT  ,inpatient,facility,,,1814,761.88,1541.9,1741.44,,1541.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1578.18,,,percent of total billed charges,,,,,,,,,1632.6,,,percent of total billed charges,,,1741.44,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1687.02,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX RENAL TROCAR NDL PERC RT,3249778,CDM,361,RC,50200,CPT,,,,,RT  ,outpatient,facility,,,1814,761.88,489.78,5933,,1541.9,,,percent of total billed charges,,,489.78,,,percent of total billed charges,,,1248.03,,,percent of total billed charges,,,1220.82,,,percent of total billed charges,,,1532.83,,,percent of total billed charges,,,,,,,,,1578.18,,,percent of total billed charges,,,1578.18,,,percent of total billed charges,,,1541.9,,,percent of total billed charges,,,1741.44,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,1632.6,,,percent of total billed charges,,,,,,,,,1687.02,,,percent of total billed charges,,,1723.3,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1650.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX RENAL TROCAR NDL PERC RT,3249778,CDM,361,RC,50200,CPT,5072,APC,,,RT  ,outpatient,facility,,,1814,1814,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX RENAL TROCAR NDL PERC BI,3249786,CDM,361,RC,50200,CPT,,,,,50,inpatient,facility,,,2721,1142.82,2312.85,2612.16,,2312.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2367.27,,,percent of total billed charges,,,,,,,,,2448.9,,,percent of total billed charges,,,2612.16,,,percent of total billed charges,,,2584.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2530.53,,,percent of total billed charges,,,2584.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX RENAL TROCAR NDL PERC BI,3249786,CDM,361,RC,50200,CPT,,,,,50,outpatient,facility,,,2721,1142.82,734.67,5933,,2312.85,,,percent of total billed charges,,,734.67,,,percent of total billed charges,,,1872.05,,,percent of total billed charges,,,1831.23,,,percent of total billed charges,,,2299.24,,,percent of total billed charges,,,,,,,,,2367.27,,,percent of total billed charges,,,2367.27,,,percent of total billed charges,,,2312.85,,,percent of total billed charges,,,2612.16,,,percent of total billed charges,,,2584.95,,,percent of total billed charges,,,,,,,,,2448.9,,,percent of total billed charges,,,,,,,,,2530.53,,,percent of total billed charges,,,2584.95,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2476.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX RENAL TROCAR NDL PERC BI,3249786,CDM,361,RC,50200,CPT,5072,APC,,,50,outpatient,facility,,,2721,2721,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INTRO NDL INTRACATHETER VEIN,3249836,CDM,361,RC,36000,CPT,,,,,,inpatient,facility,,,156,65.52,132.6,149.76,,132.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,135.72,,,percent of total billed charges,,,,,,,,,140.4,,,percent of total billed charges,,,149.76,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,145.08,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INTRO NDL INTRACATHETER VEIN,3249836,CDM,361,RC,36000,CPT,,,,,,outpatient,facility,,,156,65.52,42.12,3428,,132.6,,,percent of total billed charges,,,42.12,,,percent of total billed charges,,,107.33,,,percent of total billed charges,,,104.99,,,percent of total billed charges,,,131.82,,,percent of total billed charges,,,,,,,,,135.72,,,percent of total billed charges,,,135.72,,,percent of total billed charges,,,132.6,,,percent of total billed charges,,,149.76,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,140.4,,,percent of total billed charges,,,,,,,,,145.08,,,percent of total billed charges,,,148.2,,,percent of total billed charges,,,,,,,,,,,,,,,156,,,fee schedule,,,156,,,fee schedule,,,156,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,141.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV ILIOING ILIOHYGAS LT,3250628,CDM,361,RC,64425,CPT,,,,,LT  ,inpatient,facility,,,698,293.16,593.3,670.08,,593.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.26,,,percent of total billed charges,,,,,,,,,628.2,,,percent of total billed charges,,,670.08,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,649.14,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV ILIOING ILIOHYGAS LT,3250628,CDM,361,RC,64425,CPT,,,,,LT  ,outpatient,facility,,,698,293.16,188.46,3522,,593.3,,,percent of total billed charges,,,188.46,,,percent of total billed charges,,,480.22,,,percent of total billed charges,,,469.75,,,percent of total billed charges,,,589.81,,,percent of total billed charges,,,,,,,,,607.26,,,percent of total billed charges,,,607.26,,,percent of total billed charges,,,593.3,,,percent of total billed charges,,,670.08,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,628.2,,,percent of total billed charges,,,,,,,,,649.14,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,635.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV ILIOING ILIOHYGAS LT,3250628,CDM,361,RC,64425,CPT,5442,APC,,,LT  ,outpatient,facility,,,698,698,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV ILIOING ILIOHYGAS RT,3250636,CDM,361,RC,64425,CPT,,,,,RT  ,inpatient,facility,,,698,293.16,593.3,670.08,,593.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,607.26,,,percent of total billed charges,,,,,,,,,628.2,,,percent of total billed charges,,,670.08,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,649.14,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV ILIOING ILIOHYGAS RT,3250636,CDM,361,RC,64425,CPT,,,,,RT  ,outpatient,facility,,,698,293.16,188.46,3522,,593.3,,,percent of total billed charges,,,188.46,,,percent of total billed charges,,,480.22,,,percent of total billed charges,,,469.75,,,percent of total billed charges,,,589.81,,,percent of total billed charges,,,,,,,,,607.26,,,percent of total billed charges,,,607.26,,,percent of total billed charges,,,593.3,,,percent of total billed charges,,,670.08,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,628.2,,,percent of total billed charges,,,,,,,,,649.14,,,percent of total billed charges,,,663.1,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,635.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV ILIOING ILIOHYGAS RT,3250636,CDM,361,RC,64425,CPT,5442,APC,,,RT  ,outpatient,facility,,,698,698,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV ILIOING ILIOHYGAS BI,3250677,CDM,361,RC,64425,CPT,,,,,50,inpatient,facility,,,1047,439.74,889.95,1005.12,,889.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.89,,,percent of total billed charges,,,,,,,,,942.3,,,percent of total billed charges,,,1005.12,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,973.71,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV ILIOING ILIOHYGAS BI,3250677,CDM,361,RC,64425,CPT,,,,,50,outpatient,facility,,,1047,439.74,282.69,3522,,889.95,,,percent of total billed charges,,,282.69,,,percent of total billed charges,,,720.34,,,percent of total billed charges,,,704.63,,,percent of total billed charges,,,884.71,,,percent of total billed charges,,,,,,,,,910.89,,,percent of total billed charges,,,910.89,,,percent of total billed charges,,,889.95,,,percent of total billed charges,,,1005.12,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,942.3,,,percent of total billed charges,,,,,,,,,973.71,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,1037.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,952.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV ILIOING ILIOHYGAS BI,3250677,CDM,361,RC,64425,CPT,5442,APC,,,50,outpatient,facility,,,1047,1047,525.01,1534.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,1534.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1429,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1058.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,525.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP INTERDISCAL DX PERC,3250693,CDM,361,RC,62267,CPT,,,,,,inpatient,facility,,,1155,485.1,981.75,1108.8,,981.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1004.85,,,percent of total billed charges,,,,,,,,,1039.5,,,percent of total billed charges,,,1108.8,,,percent of total billed charges,,,1097.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1074.15,,,percent of total billed charges,,,1097.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP INTERDISCAL DX PERC,3250693,CDM,361,RC,62267,CPT,,,,,,outpatient,facility,,,1155,485.1,311.85,3522,,981.75,,,percent of total billed charges,,,311.85,,,percent of total billed charges,,,794.64,,,percent of total billed charges,,,777.31,,,percent of total billed charges,,,975.98,,,percent of total billed charges,,,,,,,,,1004.85,,,percent of total billed charges,,,1004.85,,,percent of total billed charges,,,981.75,,,percent of total billed charges,,,1108.8,,,percent of total billed charges,,,1097.25,,,percent of total billed charges,,,,,,,,,1039.5,,,percent of total billed charges,,,,,,,,,1074.15,,,percent of total billed charges,,,1097.25,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1051.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP INTERDISCAL DX PERC,3250693,CDM,361,RC,62267,CPT,5071,APC,,,,outpatient,facility,,,1155,1155,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ ANES GANGLION SPHENO LT,3250941,CDM,361,RC,64505,CPT,,,,,LT  ,inpatient,facility,,,604,253.68,513.4,579.84,,513.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.48,,,percent of total billed charges,,,,,,,,,543.6,,,percent of total billed charges,,,579.84,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.72,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ANES GANGLION SPHENO LT,3250941,CDM,361,RC,64505,CPT,,,,,LT  ,outpatient,facility,,,604,253.68,163.08,3428,,513.4,,,percent of total billed charges,,,163.08,,,percent of total billed charges,,,415.55,,,percent of total billed charges,,,406.49,,,percent of total billed charges,,,510.38,,,percent of total billed charges,,,,,,,,,525.48,,,percent of total billed charges,,,525.48,,,percent of total billed charges,,,513.4,,,percent of total billed charges,,,579.84,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,543.6,,,percent of total billed charges,,,,,,,,,561.72,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,549.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ANES GANGLION SPHENO LT,3250941,CDM,361,RC,64505,CPT,5441,APC,,,LT  ,outpatient,facility,,,604,604,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ ANES GANGLION SPHENO RT,3250958,CDM,361,RC,64505,CPT,,,,,RT  ,inpatient,facility,,,604,253.68,513.4,579.84,,513.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,525.48,,,percent of total billed charges,,,,,,,,,543.6,,,percent of total billed charges,,,579.84,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,561.72,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ANES GANGLION SPHENO RT,3250958,CDM,361,RC,64505,CPT,,,,,RT  ,outpatient,facility,,,604,253.68,163.08,3428,,513.4,,,percent of total billed charges,,,163.08,,,percent of total billed charges,,,415.55,,,percent of total billed charges,,,406.49,,,percent of total billed charges,,,510.38,,,percent of total billed charges,,,,,,,,,525.48,,,percent of total billed charges,,,525.48,,,percent of total billed charges,,,513.4,,,percent of total billed charges,,,579.84,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,543.6,,,percent of total billed charges,,,,,,,,,561.72,,,percent of total billed charges,,,573.8,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,549.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ANES GANGLION SPHENO RT,3250958,CDM,361,RC,64505,CPT,5441,APC,,,RT  ,outpatient,facility,,,604,604,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ ANES GANGLION SPHENO BI,3250966,CDM,361,RC,64505,CPT,,,,,50,inpatient,facility,,,906,380.52,770.1,869.76,,770.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,788.22,,,percent of total billed charges,,,,,,,,,815.4,,,percent of total billed charges,,,869.76,,,percent of total billed charges,,,860.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,842.58,,,percent of total billed charges,,,860.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ANES GANGLION SPHENO BI,3250966,CDM,361,RC,64505,CPT,,,,,50,outpatient,facility,,,906,380.52,244.62,3428,,770.1,,,percent of total billed charges,,,244.62,,,percent of total billed charges,,,623.33,,,percent of total billed charges,,,609.74,,,percent of total billed charges,,,765.57,,,percent of total billed charges,,,,,,,,,788.22,,,percent of total billed charges,,,788.22,,,percent of total billed charges,,,770.1,,,percent of total billed charges,,,869.76,,,percent of total billed charges,,,860.7,,,percent of total billed charges,,,,,,,,,815.4,,,percent of total billed charges,,,,,,,,,842.58,,,percent of total billed charges,,,860.7,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,824.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ANES GANGLION SPHENO BI,3250966,CDM,361,RC,64505,CPT,5441,APC,,,50,outpatient,facility,,,906,906,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV TRIGEMINAL BR LT,3251089,CDM,361,RC,64400,CPT,,,,,LT  ,inpatient,facility,,,711,298.62,604.35,682.56,,604.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,618.57,,,percent of total billed charges,,,,,,,,,639.9,,,percent of total billed charges,,,682.56,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,661.23,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV TRIGEMINAL BR LT,3251089,CDM,361,RC,64400,CPT,,,,,LT  ,outpatient,facility,,,711,298.62,191.97,3428,,604.35,,,percent of total billed charges,,,191.97,,,percent of total billed charges,,,489.17,,,percent of total billed charges,,,478.5,,,percent of total billed charges,,,600.79,,,percent of total billed charges,,,,,,,,,618.57,,,percent of total billed charges,,,618.57,,,percent of total billed charges,,,604.35,,,percent of total billed charges,,,682.56,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,639.9,,,percent of total billed charges,,,,,,,,,661.23,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,647.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV TRIGEMINAL BR LT,3251089,CDM,361,RC,64400,CPT,5441,APC,,,LT  ,outpatient,facility,,,711,711,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV TRIGEMINAL BR RT,3251097,CDM,361,RC,64400,CPT,,,,,RT  ,inpatient,facility,,,711,298.62,604.35,682.56,,604.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,618.57,,,percent of total billed charges,,,,,,,,,639.9,,,percent of total billed charges,,,682.56,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,661.23,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV TRIGEMINAL BR RT,3251097,CDM,361,RC,64400,CPT,,,,,RT  ,outpatient,facility,,,711,298.62,191.97,3428,,604.35,,,percent of total billed charges,,,191.97,,,percent of total billed charges,,,489.17,,,percent of total billed charges,,,478.5,,,percent of total billed charges,,,600.79,,,percent of total billed charges,,,,,,,,,618.57,,,percent of total billed charges,,,618.57,,,percent of total billed charges,,,604.35,,,percent of total billed charges,,,682.56,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,639.9,,,percent of total billed charges,,,,,,,,,661.23,,,percent of total billed charges,,,675.45,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,647.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV TRIGEMINAL BR RT,3251097,CDM,361,RC,64400,CPT,5441,APC,,,RT  ,outpatient,facility,,,711,711,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV TRIGEMINAL BR BI,3251113,CDM,361,RC,64400,CPT,,,,,50,inpatient,facility,,,1067,448.14,906.95,1024.32,,906.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,928.29,,,percent of total billed charges,,,,,,,,,960.3,,,percent of total billed charges,,,1024.32,,,percent of total billed charges,,,1013.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,992.31,,,percent of total billed charges,,,1013.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV TRIGEMINAL BR BI,3251113,CDM,361,RC,64400,CPT,,,,,50,outpatient,facility,,,1067,448.14,288.09,3428,,906.95,,,percent of total billed charges,,,288.09,,,percent of total billed charges,,,734.1,,,percent of total billed charges,,,718.09,,,percent of total billed charges,,,901.62,,,percent of total billed charges,,,,,,,,,928.29,,,percent of total billed charges,,,928.29,,,percent of total billed charges,,,906.95,,,percent of total billed charges,,,1024.32,,,percent of total billed charges,,,1013.65,,,percent of total billed charges,,,,,,,,,960.3,,,percent of total billed charges,,,,,,,,,992.31,,,percent of total billed charges,,,1013.65,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,970.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV TRIGEMINAL BR BI,3251113,CDM,361,RC,64400,CPT,5441,APC,,,50,outpatient,facility,,,1067,1067,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THORACENTESIS ASP WO IMG LT,3252160,CDM,361,RC,32554,CPT,,,,,LT  ,inpatient,facility,,,1836,771.12,1560.6,1762.56,,1560.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.32,,,percent of total billed charges,,,,,,,,,1652.4,,,percent of total billed charges,,,1762.56,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1707.48,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP WO IMG LT,3252160,CDM,361,RC,32554,CPT,,,,,LT  ,outpatient,facility,,,1836,771.12,495.72,3522,,1560.6,,,percent of total billed charges,,,495.72,,,percent of total billed charges,,,1263.17,,,percent of total billed charges,,,1235.63,,,percent of total billed charges,,,1551.42,,,percent of total billed charges,,,,,,,,,1597.32,,,percent of total billed charges,,,1597.32,,,percent of total billed charges,,,1560.6,,,percent of total billed charges,,,1762.56,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,1652.4,,,percent of total billed charges,,,,,,,,,1707.48,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1670.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP WO IMG LT,3252160,CDM,361,RC,32554,CPT,5181,APC,,,LT  ,outpatient,facility,,,1836,1836,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THORACENTESIS ASP WO IMG RT,3252178,CDM,361,RC,32554,CPT,,,,,RT  ,inpatient,facility,,,1836,771.12,1560.6,1762.56,,1560.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1597.32,,,percent of total billed charges,,,,,,,,,1652.4,,,percent of total billed charges,,,1762.56,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1707.48,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP WO IMG RT,3252178,CDM,361,RC,32554,CPT,,,,,RT  ,outpatient,facility,,,1836,771.12,495.72,3522,,1560.6,,,percent of total billed charges,,,495.72,,,percent of total billed charges,,,1263.17,,,percent of total billed charges,,,1235.63,,,percent of total billed charges,,,1551.42,,,percent of total billed charges,,,,,,,,,1597.32,,,percent of total billed charges,,,1597.32,,,percent of total billed charges,,,1560.6,,,percent of total billed charges,,,1762.56,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,1652.4,,,percent of total billed charges,,,,,,,,,1707.48,,,percent of total billed charges,,,1744.2,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1670.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP WO IMG RT,3252178,CDM,361,RC,32554,CPT,5181,APC,,,RT  ,outpatient,facility,,,1836,1836,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THORACENTESIS ASP WO IMG BI,3252186,CDM,361,RC,32554,CPT,,,,,50,inpatient,facility,,,2754,1156.68,2340.9,2643.84,,2340.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2395.98,,,percent of total billed charges,,,,,,,,,2478.6,,,percent of total billed charges,,,2643.84,,,percent of total billed charges,,,2616.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2561.22,,,percent of total billed charges,,,2616.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP WO IMG BI,3252186,CDM,361,RC,32554,CPT,,,,,50,outpatient,facility,,,2754,1156.68,743.58,3522,,2340.9,,,percent of total billed charges,,,743.58,,,percent of total billed charges,,,1894.75,,,percent of total billed charges,,,1853.44,,,percent of total billed charges,,,2327.13,,,percent of total billed charges,,,,,,,,,2395.98,,,percent of total billed charges,,,2395.98,,,percent of total billed charges,,,2340.9,,,percent of total billed charges,,,2643.84,,,percent of total billed charges,,,2616.3,,,percent of total billed charges,,,,,,,,,2478.6,,,percent of total billed charges,,,,,,,,,2561.22,,,percent of total billed charges,,,2616.3,,,percent of total billed charges,,,,,,,,,,,,,,,961.58,,,fee schedule,,,961.58,,,fee schedule,,,942.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2506.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP WO IMG BI,3252186,CDM,361,RC,32554,CPT,5181,APC,,,50,outpatient,facility,,,2754,2754,471.37,1394.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,980.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,961.57,,,fee schedule,,,,,,,,,,,,,,,1394.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1298.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,961.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,961.57,,,fee schedule,,,961.57,,,fee schedule,,,471.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THORACENTESIS ASP W IMG LT,3252194,CDM,361,RC,32555,CPT,,,,,LT  ,inpatient,facility,,,2715,1140.3,2307.75,2606.4,,2307.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2362.05,,,percent of total billed charges,,,,,,,,,2443.5,,,percent of total billed charges,,,2606.4,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2524.95,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP W IMG LT,3252194,CDM,361,RC,32555,CPT,,,,,LT  ,outpatient,facility,,,2715,1140.3,628.23,3522,,2307.75,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,,1867.92,,,percent of total billed charges,,,1827.19,,,percent of total billed charges,,,2294.17,,,percent of total billed charges,,,,,,,,,2362.05,,,percent of total billed charges,,,2362.05,,,percent of total billed charges,,,2307.75,,,percent of total billed charges,,,2606.4,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,2443.5,,,percent of total billed charges,,,,,,,,,2524.95,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2470.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP W IMG LT,3252194,CDM,361,RC,32555,CPT,5181,APC,,,LT  ,outpatient,facility,,,2715,2715,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THORACENTESIS ASP W IMG RT,3252202,CDM,361,RC,32555,CPT,,,,,RT  ,inpatient,facility,,,2715,1140.3,2307.75,2606.4,,2307.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2362.05,,,percent of total billed charges,,,,,,,,,2443.5,,,percent of total billed charges,,,2606.4,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2524.95,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP W IMG RT,3252202,CDM,361,RC,32555,CPT,,,,,RT  ,outpatient,facility,,,2715,1140.3,628.23,3522,,2307.75,,,percent of total billed charges,,,733.05,,,percent of total billed charges,,,1867.92,,,percent of total billed charges,,,1827.19,,,percent of total billed charges,,,2294.17,,,percent of total billed charges,,,,,,,,,2362.05,,,percent of total billed charges,,,2362.05,,,percent of total billed charges,,,2307.75,,,percent of total billed charges,,,2606.4,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,2443.5,,,percent of total billed charges,,,,,,,,,2524.95,,,percent of total billed charges,,,2579.25,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2470.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP W IMG RT,3252202,CDM,361,RC,32555,CPT,5181,APC,,,RT  ,outpatient,facility,,,2715,2715,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THORACENTESIS ASP W IMG BI,3252210,CDM,361,RC,32555,CPT,,,,,50,inpatient,facility,,,4072,1710.24,3461.2,3909.12,,3461.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3542.64,,,percent of total billed charges,,,,,,,,,3664.8,,,percent of total billed charges,,,3909.12,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3786.96,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP W IMG BI,3252210,CDM,361,RC,32555,CPT,,,,,50,outpatient,facility,,,4072,1710.24,942.35,3909.12,,3461.2,,,percent of total billed charges,,,1099.44,,,percent of total billed charges,,,2801.54,,,percent of total billed charges,,,2740.46,,,percent of total billed charges,,,3440.84,,,percent of total billed charges,,,,,,,,,3542.64,,,percent of total billed charges,,,3542.64,,,percent of total billed charges,,,3461.2,,,percent of total billed charges,,,3909.12,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,3664.8,,,percent of total billed charges,,,,,,,,,3786.96,,,percent of total billed charges,,,3868.4,,,percent of total billed charges,,,,,,,,,,,,,,,961.58,,,fee schedule,,,961.58,,,fee schedule,,,942.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,3705.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THORACENTESIS ASP W IMG BI,3252210,CDM,361,RC,32555,CPT,5181,APC,,,50,outpatient,facility,,,4072,4072,471.37,1394.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,980.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,961.57,,,fee schedule,,,,,,,,,,,,,,,1394.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1298.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,961.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,961.57,,,fee schedule,,,961.57,,,fee schedule,,,471.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE CERVICAL 4 5 VW,3252293,CDM,320,RC,72050,CPT,,,,,,inpatient,facility,,,153,64.26,130.05,146.88,,130.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,133.11,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE CERVICAL 4 5 VW,3252293,CDM,320,RC,72050,CPT,,,,,,outpatient,facility,,,153,64.26,41.31,146.88,,130.05,,,percent of total billed charges,,,41.31,,,percent of total billed charges,,,105.26,,,percent of total billed charges,,,102.97,,,percent of total billed charges,,,129.28,,,percent of total billed charges,,,,,,,,,133.11,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,130.05,,,percent of total billed charges,,,146.88,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,137.7,,,percent of total billed charges,,,,,,,,,142.29,,,percent of total billed charges,,,145.35,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,119.49,,,percent of total billed charges,,,139.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE CERVICAL 4 5 VW,3252293,CDM,320,RC,72050,CPT,5522,APC,,,,outpatient,facility,,,153,153,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR SPINE CERVICAL 6 PLUS VW,3252301,CDM,320,RC,72052,CPT,,,,,,inpatient,facility,,,182,76.44,154.7,174.72,,154.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,158.34,,,percent of total billed charges,,,,,,,,,163.8,,,percent of total billed charges,,,174.72,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,169.26,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR SPINE CERVICAL 6 PLUS VW,3252301,CDM,320,RC,72052,CPT,,,,,,outpatient,facility,,,182,76.44,49.14,174.72,,154.7,,,percent of total billed charges,,,49.14,,,percent of total billed charges,,,125.22,,,percent of total billed charges,,,122.49,,,percent of total billed charges,,,153.79,,,percent of total billed charges,,,,,,,,,158.34,,,percent of total billed charges,,,158.34,,,percent of total billed charges,,,154.7,,,percent of total billed charges,,,174.72,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,163.8,,,percent of total billed charges,,,,,,,,,169.26,,,percent of total billed charges,,,172.9,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,142.14,,,percent of total billed charges,,,165.62,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR SPINE CERVICAL 6 PLUS VW,3252301,CDM,320,RC,72052,CPT,5522,APC,,,,outpatient,facility,,,182,182,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ANGIO SUBSQ THRPY EMB INF NONTHROMB,3252434,CDM,323,RC,75898,CPT,,,,,,inpatient,facility,,,1308,549.36,1111.8,1255.68,,1111.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1137.96,,,percent of total billed charges,,,,,,,,,1177.2,,,percent of total billed charges,,,1255.68,,,percent of total billed charges,,,1242.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1216.44,,,percent of total billed charges,,,1242.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ANGIO SUBSQ THRPY EMB INF NONTHROMB,3252434,CDM,323,RC,75898,CPT,,,,,,outpatient,facility,,,1308,549.36,353.16,1308,,1111.8,,,percent of total billed charges,,,353.16,,,percent of total billed charges,,,899.9,,,percent of total billed charges,,,880.28,,,percent of total billed charges,,,1105.26,,,percent of total billed charges,,,,,,,,,1137.96,,,percent of total billed charges,,,1137.96,,,percent of total billed charges,,,1111.8,,,percent of total billed charges,,,1255.68,,,percent of total billed charges,,,1242.6,,,percent of total billed charges,,,,,,,,,1177.2,,,percent of total billed charges,,,,,,,,,1216.44,,,percent of total billed charges,,,1242.6,,,percent of total billed charges,,,,,,,,,,,,,,,1308,,,fee schedule,,,1308,,,fee schedule,,,1308,,,fee schedule,,,,,,,,,1021.55,,,percent of total billed charges,,,1190.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ANGIO SUBSQ THRPY EMB INF NONTHROMB,3252434,CDM,323,RC,75898,CPT,5183,APC,,,,outpatient,facility,,,1308,1308,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN PLEURA INS CATH INDWL W IMG LT,3252624,CDM,361,RC,32557,CPT,,,,,LT  ,inpatient,facility,,,2347,985.74,1994.95,2253.12,,1994.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2041.89,,,percent of total billed charges,,,,,,,,,2112.3,,,percent of total billed charges,,,2253.12,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2182.71,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN PLEURA INS CATH INDWL W IMG LT,3252624,CDM,361,RC,32557,CPT,,,,,LT  ,outpatient,facility,,,2347,985.74,633.69,3522,,1994.95,,,percent of total billed charges,,,633.69,,,percent of total billed charges,,,1614.74,,,percent of total billed charges,,,1579.53,,,percent of total billed charges,,,1983.21,,,percent of total billed charges,,,,,,,,,2041.89,,,percent of total billed charges,,,2041.89,,,percent of total billed charges,,,1994.95,,,percent of total billed charges,,,2253.12,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,2112.3,,,percent of total billed charges,,,,,,,,,2182.71,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2135.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN PLEURA INS CATH INDWL W IMG LT,3252624,CDM,361,RC,32557,CPT,5182,APC,,,LT  ,outpatient,facility,,,2347,2347,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN PLEURA INS CATH INDWL W IMG RT,3252632,CDM,361,RC,32557,CPT,,,,,RT  ,inpatient,facility,,,2347,985.74,1994.95,2253.12,,1994.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2041.89,,,percent of total billed charges,,,,,,,,,2112.3,,,percent of total billed charges,,,2253.12,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2182.71,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN PLEURA INS CATH INDWL W IMG RT,3252632,CDM,361,RC,32557,CPT,,,,,RT  ,outpatient,facility,,,2347,985.74,633.69,3522,,1994.95,,,percent of total billed charges,,,633.69,,,percent of total billed charges,,,1614.74,,,percent of total billed charges,,,1579.53,,,percent of total billed charges,,,1983.21,,,percent of total billed charges,,,,,,,,,2041.89,,,percent of total billed charges,,,2041.89,,,percent of total billed charges,,,1994.95,,,percent of total billed charges,,,2253.12,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,2112.3,,,percent of total billed charges,,,,,,,,,2182.71,,,percent of total billed charges,,,2229.65,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2135.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN PLEURA INS CATH INDWL W IMG RT,3252632,CDM,361,RC,32557,CPT,5182,APC,,,RT  ,outpatient,facility,,,2347,2347,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN PLEURA INS CATH INDWL W IMG BI,3252640,CDM,361,RC,32557,CPT,,,,,50,inpatient,facility,,,3520,1478.4,2992,3379.2,,2992,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3062.4,,,percent of total billed charges,,,,,,,,,3168,,,percent of total billed charges,,,3379.2,,,percent of total billed charges,,,3344,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3273.6,,,percent of total billed charges,,,3344,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN PLEURA INS CATH INDWL W IMG BI,3252640,CDM,361,RC,32557,CPT,,,,,50,outpatient,facility,,,3520,1478.4,950.4,3522,,2992,,,percent of total billed charges,,,950.4,,,percent of total billed charges,,,2421.76,,,percent of total billed charges,,,2368.96,,,percent of total billed charges,,,2974.4,,,percent of total billed charges,,,,,,,,,3062.4,,,percent of total billed charges,,,3062.4,,,percent of total billed charges,,,2992,,,percent of total billed charges,,,3379.2,,,percent of total billed charges,,,3344,,,percent of total billed charges,,,,,,,,,3168,,,percent of total billed charges,,,,,,,,,3273.6,,,percent of total billed charges,,,3344,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,3203.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN PLEURA INS CATH INDWL W IMG BI,3252640,CDM,361,RC,32557,CPT,5183,APC,,,50,outpatient,facility,,,3520,3520,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL URETER(S) URETHRA S ANDI,3252830,CDM,320,RC,74485,CPT,,,,,,inpatient,facility,,,909,381.78,772.65,872.64,,772.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.83,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL URETER(S) URETHRA S ANDI,3252830,CDM,320,RC,74485,CPT,,,,,,outpatient,facility,,,909,381.78,245.43,2078.45,,772.65,,,percent of total billed charges,,,245.43,,,percent of total billed charges,,,625.39,,,percent of total billed charges,,,611.76,,,percent of total billed charges,,,768.11,,,percent of total billed charges,,,,,,,,,790.83,,,percent of total billed charges,,,790.83,,,percent of total billed charges,,,772.65,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,2036.88,,,fee schedule,,,,,,,,,709.93,,,percent of total billed charges,,,827.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL URETER(S) URETHRA S ANDI,3252830,CDM,320,RC,74485,CPT,5373,APC,,,,outpatient,facility,,,909,909,1007.57,3013.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2120.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,2078.45,,,fee schedule,,,,,,,,,,,,,,,3013.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2805.91,,,fee schedule,,,,,,,,,,,,,,,,,,,,,2078.45,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,2078.45,,,fee schedule,,,2078.45,,,fee schedule,,,1007.57,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
REM FB INTRAVASC W IMG S ANDI,3252962,CDM,361,RC,37197,CPT,,,,,,inpatient,facility,,,8223,3453.66,6989.55,7894.08,,6989.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7154.01,,,percent of total billed charges,,,,,,,,,7400.7,,,percent of total billed charges,,,7894.08,,,percent of total billed charges,,,7811.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7647.39,,,percent of total billed charges,,,7811.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
REM FB INTRAVASC W IMG S ANDI,3252962,CDM,361,RC,37197,CPT,,,,,,outpatient,facility,,,8223,3453.66,2220.21,15487,,6989.55,,,percent of total billed charges,,,2220.21,,,percent of total billed charges,,,5657.42,,,percent of total billed charges,,,5534.08,,,percent of total billed charges,,,6948.43,,,percent of total billed charges,,,,,,,,,7154.01,,,percent of total billed charges,,,7154.01,,,percent of total billed charges,,,6989.55,,,percent of total billed charges,,,7894.08,,,percent of total billed charges,,,7811.85,,,percent of total billed charges,,,,,,,,,7400.7,,,percent of total billed charges,,,,,,,,,7647.39,,,percent of total billed charges,,,7811.85,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,7482.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
REM FB INTRAVASC W IMG S ANDI,3252962,CDM,361,RC,37197,CPT,5183,APC,,,,outpatient,facility,,,8223,8223,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBOLYSIS INF ART INIT DAY S ANDI,3252970,CDM,361,RC,37211,CPT,,,,,,inpatient,facility,,,32739,13750.38,27828.15,31429.44,,27828.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,28482.93,,,percent of total billed charges,,,,,,,,,29465.1,,,percent of total billed charges,,,31429.44,,,percent of total billed charges,,,31102.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,30447.27,,,percent of total billed charges,,,31102.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF ART INIT DAY S ANDI,3252970,CDM,361,RC,37211,CPT,,,,,,outpatient,facility,,,32739,13750.38,8839.53,32739,,27828.15,,,percent of total billed charges,,,8839.53,,,percent of total billed charges,,,22524.43,,,percent of total billed charges,,,22033.35,,,percent of total billed charges,,,27664.45,,,percent of total billed charges,,,,,,,,,28482.93,,,percent of total billed charges,,,28482.93,,,percent of total billed charges,,,27828.15,,,percent of total billed charges,,,31429.44,,,percent of total billed charges,,,31102.05,,,percent of total billed charges,,,,,,,,,29465.1,,,percent of total billed charges,,,,,,,,,30447.27,,,percent of total billed charges,,,31102.05,,,percent of total billed charges,,,,,,,,,,,,,,,32739,,,fee schedule,,,32739,,,fee schedule,,,32739,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,29792.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF ART INIT DAY S ANDI,3252970,CDM,361,RC,37211,CPT,5184,APC,,,,outpatient,facility,,,32739,32739,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBOLYSIS INF VEN INIT S ANDI,3252988,CDM,361,RC,37212,CPT,,,,,,inpatient,facility,,,28673,12042.66,24372.05,27526.08,,24372.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,24945.51,,,percent of total billed charges,,,,,,,,,25805.7,,,percent of total billed charges,,,27526.08,,,percent of total billed charges,,,27239.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,26665.89,,,percent of total billed charges,,,27239.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF VEN INIT S ANDI,3252988,CDM,361,RC,37212,CPT,,,,,,outpatient,facility,,,28673,12042.66,3187.59,27526.08,,24372.05,,,percent of total billed charges,,,7741.71,,,percent of total billed charges,,,19727.02,,,percent of total billed charges,,,19296.93,,,percent of total billed charges,,,24228.68,,,percent of total billed charges,,,,,,,,,24945.51,,,percent of total billed charges,,,24945.51,,,percent of total billed charges,,,24372.05,,,percent of total billed charges,,,27526.08,,,percent of total billed charges,,,27239.35,,,percent of total billed charges,,,,,,,,,25805.7,,,percent of total billed charges,,,,,,,,,26665.89,,,percent of total billed charges,,,27239.35,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,26092.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF VEN INIT S ANDI,3252988,CDM,361,RC,37212,CPT,5183,APC,,,,outpatient,facility,,,28673,28673,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THROMBOLYSIS INF ART VEN SUBSQ S ANDI,3252996,CDM,361,RC,37213,CPT,,,,,,inpatient,facility,,,19810,8320.2,16838.5,19017.6,,16838.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17234.7,,,percent of total billed charges,,,,,,,,,17829,,,percent of total billed charges,,,19017.6,,,percent of total billed charges,,,18819.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18423.3,,,percent of total billed charges,,,18819.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF ART VEN SUBSQ S ANDI,3252996,CDM,361,RC,37213,CPT,,,,,,outpatient,facility,,,19810,8320.2,3187.59,19017.6,,16838.5,,,percent of total billed charges,,,5348.7,,,percent of total billed charges,,,13629.28,,,percent of total billed charges,,,13332.13,,,percent of total billed charges,,,16739.45,,,percent of total billed charges,,,,,,,,,17234.7,,,percent of total billed charges,,,17234.7,,,percent of total billed charges,,,16838.5,,,percent of total billed charges,,,19017.6,,,percent of total billed charges,,,18819.5,,,percent of total billed charges,,,,,,,,,17829,,,percent of total billed charges,,,,,,,,,18423.3,,,percent of total billed charges,,,18819.5,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,18027.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THROMBOLYSIS INF ART VEN SUBSQ S ANDI,3252996,CDM,361,RC,37213,CPT,5183,APC,,,,outpatient,facility,,,19810,19810,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CESSAT THROMBOLYSIS ANDREM CATH S ANDI,3253002,CDM,361,RC,37214,CPT,,,,,,inpatient,facility,,,10427,4379.34,8862.95,10009.92,,8862.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9071.49,,,percent of total billed charges,,,,,,,,,9384.3,,,percent of total billed charges,,,10009.92,,,percent of total billed charges,,,9905.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9697.11,,,percent of total billed charges,,,9905.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CESSAT THROMBOLYSIS ANDREM CATH S ANDI,3253002,CDM,361,RC,37214,CPT,,,,,,outpatient,facility,,,10427,4379.34,2815.29,10009.92,,8862.95,,,percent of total billed charges,,,2815.29,,,percent of total billed charges,,,7173.78,,,percent of total billed charges,,,7017.37,,,percent of total billed charges,,,8810.82,,,percent of total billed charges,,,,,,,,,9071.49,,,percent of total billed charges,,,9071.49,,,percent of total billed charges,,,8862.95,,,percent of total billed charges,,,10009.92,,,percent of total billed charges,,,9905.65,,,percent of total billed charges,,,,,,,,,9384.3,,,percent of total billed charges,,,,,,,,,9697.11,,,percent of total billed charges,,,9905.65,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,9488.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CESSAT THROMBOLYSIS ANDREM CATH S ANDI,3253002,CDM,361,RC,37214,CPT,5183,APC,,,,outpatient,facility,,,10427,10427,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH AORTA THOR ANG EC AND IC S ANDI,3253010,CDM,361,RC,36221,CPT,,,,,,inpatient,facility,,,8358,3510.36,7104.3,8023.68,,7104.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7271.46,,,percent of total billed charges,,,,,,,,,7522.2,,,percent of total billed charges,,,8023.68,,,percent of total billed charges,,,7940.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7772.94,,,percent of total billed charges,,,7940.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH AORTA THOR ANG EC AND IC S ANDI,3253010,CDM,361,RC,36221,CPT,,,,,,outpatient,facility,,,8358,3510.36,2256.66,15487,,7104.3,,,percent of total billed charges,,,2256.66,,,percent of total billed charges,,,5750.3,,,percent of total billed charges,,,5624.93,,,percent of total billed charges,,,7062.51,,,percent of total billed charges,,,,,,,,,7271.46,,,percent of total billed charges,,,7271.46,,,percent of total billed charges,,,7104.3,,,percent of total billed charges,,,8023.68,,,percent of total billed charges,,,7940.1,,,percent of total billed charges,,,,,,,,,7522.2,,,percent of total billed charges,,,,,,,,,7772.94,,,percent of total billed charges,,,7940.1,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,7605.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH AORTA THOR ANG EC AND IC S ANDI,3253010,CDM,361,RC,36221,CPT,5183,APC,,,,outpatient,facility,,,8358,8358,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL CAR INM ANG EC LT S ANDI,3253044,CDM,361,RC,36222,CPT,,,,,LT  ,inpatient,facility,,,11940,5014.8,10149,11462.4,,10149,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10387.8,,,percent of total billed charges,,,,,,,,,10746,,,percent of total billed charges,,,11462.4,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11104.2,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG EC LT S ANDI,3253044,CDM,361,RC,36222,CPT,,,,,LT  ,outpatient,facility,,,11940,5014.8,3187.59,15487,,10149,,,percent of total billed charges,,,3223.8,,,percent of total billed charges,,,8214.72,,,percent of total billed charges,,,8035.62,,,percent of total billed charges,,,10089.3,,,percent of total billed charges,,,,,,,,,10387.8,,,percent of total billed charges,,,10387.8,,,percent of total billed charges,,,10149,,,percent of total billed charges,,,11462.4,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,10746,,,percent of total billed charges,,,,,,,,,11104.2,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,10865.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG EC LT S ANDI,3253044,CDM,361,RC,36222,CPT,5183,APC,,,LT  ,outpatient,facility,,,11940,11940,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL CAR INM ANG EC RT S ANDI,3253051,CDM,361,RC,36222,CPT,,,,,RT  ,inpatient,facility,,,11940,5014.8,10149,11462.4,,10149,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10387.8,,,percent of total billed charges,,,,,,,,,10746,,,percent of total billed charges,,,11462.4,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11104.2,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG EC RT S ANDI,3253051,CDM,361,RC,36222,CPT,,,,,RT  ,outpatient,facility,,,11940,5014.8,3187.59,15487,,10149,,,percent of total billed charges,,,3223.8,,,percent of total billed charges,,,8214.72,,,percent of total billed charges,,,8035.62,,,percent of total billed charges,,,10089.3,,,percent of total billed charges,,,,,,,,,10387.8,,,percent of total billed charges,,,10387.8,,,percent of total billed charges,,,10149,,,percent of total billed charges,,,11462.4,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,10746,,,percent of total billed charges,,,,,,,,,11104.2,,,percent of total billed charges,,,11343,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,10865.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG EC RT S ANDI,3253051,CDM,361,RC,36222,CPT,5183,APC,,,RT  ,outpatient,facility,,,11940,11940,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL CAR INM ANG EC BI S ANDI,3253069,CDM,361,RC,36222,CPT,,,,,50,inpatient,facility,,,17910,7522.2,15223.5,17193.6,,15223.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,15581.7,,,percent of total billed charges,,,,,,,,,16119,,,percent of total billed charges,,,17193.6,,,percent of total billed charges,,,17014.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,16656.3,,,percent of total billed charges,,,17014.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG EC BI S ANDI,3253069,CDM,361,RC,36222,CPT,,,,,50,outpatient,facility,,,17910,7522.2,3187.59,17193.6,,15223.5,,,percent of total billed charges,,,4835.7,,,percent of total billed charges,,,12322.08,,,percent of total billed charges,,,12053.43,,,percent of total billed charges,,,15133.95,,,percent of total billed charges,,,,,,,,,15581.7,,,percent of total billed charges,,,15581.7,,,percent of total billed charges,,,15223.5,,,percent of total billed charges,,,17193.6,,,percent of total billed charges,,,17014.5,,,percent of total billed charges,,,,,,,,,16119,,,percent of total billed charges,,,,,,,,,16656.3,,,percent of total billed charges,,,17014.5,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,16298.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG EC BI S ANDI,3253069,CDM,361,RC,36222,CPT,5183,APC,,,50,outpatient,facility,,,17910,17910,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL CAR INM ANG IC LT S ANDI,3253077,CDM,361,RC,36223,CPT,,,,,LT  ,inpatient,facility,,,13267,5572.14,11276.95,12736.32,,11276.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11542.29,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG IC LT S ANDI,3253077,CDM,361,RC,36223,CPT,,,,,LT  ,outpatient,facility,,,13267,5572.14,3582.09,28046,,11276.95,,,percent of total billed charges,,,3582.09,,,percent of total billed charges,,,9127.7,,,percent of total billed charges,,,8928.69,,,percent of total billed charges,,,11210.61,,,percent of total billed charges,,,,,,,,,11542.29,,,percent of total billed charges,,,11542.29,,,percent of total billed charges,,,11276.95,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,12072.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG IC LT S ANDI,3253077,CDM,361,RC,36223,CPT,5184,APC,,,LT  ,outpatient,facility,,,13267,13267,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL CAR INM ANG IC RT S ANDI,3253085,CDM,361,RC,36223,CPT,,,,,RT  ,inpatient,facility,,,13267,5572.14,11276.95,12736.32,,11276.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11542.29,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG IC RT S ANDI,3253085,CDM,361,RC,36223,CPT,,,,,RT  ,outpatient,facility,,,13267,5572.14,3582.09,28046,,11276.95,,,percent of total billed charges,,,3582.09,,,percent of total billed charges,,,9127.7,,,percent of total billed charges,,,8928.69,,,percent of total billed charges,,,11210.61,,,percent of total billed charges,,,,,,,,,11542.29,,,percent of total billed charges,,,11542.29,,,percent of total billed charges,,,11276.95,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,12072.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG IC RT S ANDI,3253085,CDM,361,RC,36223,CPT,5184,APC,,,RT  ,outpatient,facility,,,13267,13267,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL CAR INM ANG IC BI S ANDI,3253093,CDM,361,RC,36223,CPT,,,,,50,inpatient,facility,,,19900,8358,16915,19104,,16915,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17313,,,percent of total billed charges,,,,,,,,,17910,,,percent of total billed charges,,,19104,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18507,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG IC BI S ANDI,3253093,CDM,361,RC,36223,CPT,,,,,50,outpatient,facility,,,19900,8358,5373,28046,,16915,,,percent of total billed charges,,,5373,,,percent of total billed charges,,,13691.2,,,percent of total billed charges,,,13392.7,,,percent of total billed charges,,,16815.5,,,percent of total billed charges,,,,,,,,,17313,,,percent of total billed charges,,,17313,,,percent of total billed charges,,,16915,,,percent of total billed charges,,,19104,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,17910,,,percent of total billed charges,,,,,,,,,18507,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,18109,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL CAR INM ANG IC BI S ANDI,3253093,CDM,361,RC,36223,CPT,5184,APC,,,50,outpatient,facility,,,19900,19900,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART CAR ANG IC LT S ANDI,3253101,CDM,361,RC,36224,CPT,,,,,LT  ,inpatient,facility,,,15124,6352.08,12855.4,14519.04,,12855.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13157.88,,,percent of total billed charges,,,,,,,,,13611.6,,,percent of total billed charges,,,14519.04,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14065.32,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR ANG IC LT S ANDI,3253101,CDM,361,RC,36224,CPT,,,,,LT  ,outpatient,facility,,,15124,6352.08,4083.48,28046,,12855.4,,,percent of total billed charges,,,4083.48,,,percent of total billed charges,,,10405.31,,,percent of total billed charges,,,10178.45,,,percent of total billed charges,,,12779.78,,,percent of total billed charges,,,,,,,,,13157.88,,,percent of total billed charges,,,13157.88,,,percent of total billed charges,,,12855.4,,,percent of total billed charges,,,14519.04,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,13611.6,,,percent of total billed charges,,,,,,,,,14065.32,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,13762.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR ANG IC LT S ANDI,3253101,CDM,361,RC,36224,CPT,5184,APC,,,LT  ,outpatient,facility,,,15124,15124,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART CAR ANG IC RT S ANDI,3253119,CDM,361,RC,36224,CPT,,,,,RT  ,inpatient,facility,,,15124,6352.08,12855.4,14519.04,,12855.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13157.88,,,percent of total billed charges,,,,,,,,,13611.6,,,percent of total billed charges,,,14519.04,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14065.32,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR ANG IC RT S ANDI,3253119,CDM,361,RC,36224,CPT,,,,,RT  ,outpatient,facility,,,15124,6352.08,4083.48,28046,,12855.4,,,percent of total billed charges,,,4083.48,,,percent of total billed charges,,,10405.31,,,percent of total billed charges,,,10178.45,,,percent of total billed charges,,,12779.78,,,percent of total billed charges,,,,,,,,,13157.88,,,percent of total billed charges,,,13157.88,,,percent of total billed charges,,,12855.4,,,percent of total billed charges,,,14519.04,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,13611.6,,,percent of total billed charges,,,,,,,,,14065.32,,,percent of total billed charges,,,14367.8,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,13762.84,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR ANG IC RT S ANDI,3253119,CDM,361,RC,36224,CPT,5184,APC,,,RT  ,outpatient,facility,,,15124,15124,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART CAR ANG IC BI S ANDI,3253127,CDM,361,RC,36224,CPT,,,,,50,inpatient,facility,,,22686,9528.12,19283.1,21778.56,,19283.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19736.82,,,percent of total billed charges,,,,,,,,,20417.4,,,percent of total billed charges,,,21778.56,,,percent of total billed charges,,,21551.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,21097.98,,,percent of total billed charges,,,21551.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR ANG IC BI S ANDI,3253127,CDM,361,RC,36224,CPT,,,,,50,outpatient,facility,,,22686,9528.12,5495.52,28046,,19283.1,,,percent of total billed charges,,,6125.22,,,percent of total billed charges,,,15607.97,,,percent of total billed charges,,,15267.68,,,percent of total billed charges,,,19169.67,,,percent of total billed charges,,,,,,,,,19736.82,,,percent of total billed charges,,,19736.82,,,percent of total billed charges,,,19283.1,,,percent of total billed charges,,,21778.56,,,percent of total billed charges,,,21551.7,,,percent of total billed charges,,,,,,,,,20417.4,,,percent of total billed charges,,,,,,,,,21097.98,,,percent of total billed charges,,,21551.7,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,20644.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR ANG IC BI S ANDI,3253127,CDM,361,RC,36224,CPT,5184,APC,,,50,outpatient,facility,,,22686,22686,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART SUB INM ANG LT S ANDI,3253135,CDM,361,RC,36225,CPT,,,,,LT  ,inpatient,facility,,,13267,5572.14,11276.95,12736.32,,11276.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11542.29,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART SUB INM ANG LT S ANDI,3253135,CDM,361,RC,36225,CPT,,,,,LT  ,outpatient,facility,,,13267,5572.14,3187.59,15487,,11276.95,,,percent of total billed charges,,,3582.09,,,percent of total billed charges,,,9127.7,,,percent of total billed charges,,,8928.69,,,percent of total billed charges,,,11210.61,,,percent of total billed charges,,,,,,,,,11542.29,,,percent of total billed charges,,,11542.29,,,percent of total billed charges,,,11276.95,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,12072.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART SUB INM ANG LT S ANDI,3253135,CDM,361,RC,36225,CPT,5183,APC,,,LT  ,outpatient,facility,,,13267,13267,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART SUB INM ANG RT S ANDI,3253143,CDM,361,RC,36225,CPT,,,,,RT  ,inpatient,facility,,,13267,5572.14,11276.95,12736.32,,11276.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11542.29,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART SUB INM ANG RT S ANDI,3253143,CDM,361,RC,36225,CPT,,,,,RT  ,outpatient,facility,,,13267,5572.14,3187.59,15487,,11276.95,,,percent of total billed charges,,,3582.09,,,percent of total billed charges,,,9127.7,,,percent of total billed charges,,,8928.69,,,percent of total billed charges,,,11210.61,,,percent of total billed charges,,,,,,,,,11542.29,,,percent of total billed charges,,,11542.29,,,percent of total billed charges,,,11276.95,,,percent of total billed charges,,,12736.32,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,11940.3,,,percent of total billed charges,,,,,,,,,12338.31,,,percent of total billed charges,,,12603.65,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,12072.97,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART SUB INM ANG RT S ANDI,3253143,CDM,361,RC,36225,CPT,5183,APC,,,RT  ,outpatient,facility,,,13267,13267,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART SUB INM ANG BI S ANDI,3253150,CDM,361,RC,36225,CPT,,,,,50,inpatient,facility,,,19900,8358,16915,19104,,16915,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17313,,,percent of total billed charges,,,,,,,,,17910,,,percent of total billed charges,,,19104,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18507,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART SUB INM ANG BI S ANDI,3253150,CDM,361,RC,36225,CPT,,,,,50,outpatient,facility,,,19900,8358,3187.59,19104,,16915,,,percent of total billed charges,,,5373,,,percent of total billed charges,,,13691.2,,,percent of total billed charges,,,13392.7,,,percent of total billed charges,,,16815.5,,,percent of total billed charges,,,,,,,,,17313,,,percent of total billed charges,,,17313,,,percent of total billed charges,,,16915,,,percent of total billed charges,,,19104,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,17910,,,percent of total billed charges,,,,,,,,,18507,,,percent of total billed charges,,,18905,,,percent of total billed charges,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,3187.59,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,18109,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART SUB INM ANG BI S ANDI,3253150,CDM,361,RC,36225,CPT,5183,APC,,,50,outpatient,facility,,,19900,19900,1618.19,4716.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3317.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3252.64,,,fee schedule,,,,,,,,,,,,,,,4716.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4391.06,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3252.64,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3252.64,,,fee schedule,,,3252.64,,,fee schedule,,,1618.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART VERT ANG LT S ANDI,3253168,CDM,361,RC,36226,CPT,,,,,LT  ,inpatient,facility,,,14859,6240.78,12630.15,14264.64,,12630.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12927.33,,,percent of total billed charges,,,,,,,,,13373.1,,,percent of total billed charges,,,14264.64,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13818.87,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART VERT ANG LT S ANDI,3253168,CDM,361,RC,36226,CPT,,,,,LT  ,outpatient,facility,,,14859,6240.78,4011.93,28046,,12630.15,,,percent of total billed charges,,,4011.93,,,percent of total billed charges,,,10222.99,,,percent of total billed charges,,,10000.11,,,percent of total billed charges,,,12555.85,,,percent of total billed charges,,,,,,,,,12927.33,,,percent of total billed charges,,,12927.33,,,percent of total billed charges,,,12630.15,,,percent of total billed charges,,,14264.64,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,13373.1,,,percent of total billed charges,,,,,,,,,13818.87,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,13521.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART VERT ANG LT S ANDI,3253168,CDM,361,RC,36226,CPT,5184,APC,,,LT  ,outpatient,facility,,,14859,14859,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART VERT ANG RT S ANDI,3253176,CDM,361,RC,36226,CPT,,,,,RT  ,inpatient,facility,,,14859,6240.78,12630.15,14264.64,,12630.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12927.33,,,percent of total billed charges,,,,,,,,,13373.1,,,percent of total billed charges,,,14264.64,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13818.87,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART VERT ANG RT S ANDI,3253176,CDM,361,RC,36226,CPT,,,,,RT  ,outpatient,facility,,,14859,6240.78,4011.93,28046,,12630.15,,,percent of total billed charges,,,4011.93,,,percent of total billed charges,,,10222.99,,,percent of total billed charges,,,10000.11,,,percent of total billed charges,,,12555.85,,,percent of total billed charges,,,,,,,,,12927.33,,,percent of total billed charges,,,12927.33,,,percent of total billed charges,,,12630.15,,,percent of total billed charges,,,14264.64,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,13373.1,,,percent of total billed charges,,,,,,,,,13818.87,,,percent of total billed charges,,,14116.05,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,13521.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART VERT ANG RT S ANDI,3253176,CDM,361,RC,36226,CPT,5184,APC,,,RT  ,outpatient,facility,,,14859,14859,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART VERT ANG BI S ANDI,3253184,CDM,361,RC,36226,CPT,,,,,50,inpatient,facility,,,22288,9360.96,18944.8,21396.48,,18944.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,19390.56,,,percent of total billed charges,,,,,,,,,20059.2,,,percent of total billed charges,,,21396.48,,,percent of total billed charges,,,21173.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,20727.84,,,percent of total billed charges,,,21173.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART VERT ANG BI S ANDI,3253184,CDM,361,RC,36226,CPT,,,,,50,outpatient,facility,,,22288,9360.96,5495.52,28046,,18944.8,,,percent of total billed charges,,,6017.76,,,percent of total billed charges,,,15334.14,,,percent of total billed charges,,,14999.82,,,percent of total billed charges,,,18833.36,,,percent of total billed charges,,,,,,,,,19390.56,,,percent of total billed charges,,,19390.56,,,percent of total billed charges,,,18944.8,,,percent of total billed charges,,,21396.48,,,percent of total billed charges,,,21173.6,,,percent of total billed charges,,,,,,,,,20059.2,,,percent of total billed charges,,,,,,,,,20727.84,,,percent of total billed charges,,,21173.6,,,percent of total billed charges,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,5495.52,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,20282.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART VERT ANG BI S ANDI,3253184,CDM,361,RC,36226,CPT,5184,APC,,,50,outpatient,facility,,,22288,22288,2791.93,8131.12,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5719.82,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5607.67,,,fee schedule,,,,,,,,,,,,,,,8131.12,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7570.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5607.67,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5607.67,,,fee schedule,,,5607.67,,,fee schedule,,,2791.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC CATH SEL ART CAR EXT ANG LT S ANDI,3253192,CDM,361,RC,36227,CPT,,,,,LT  ,inpatient,facility,,,4909,2061.78,4172.65,4712.64,,4172.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4270.83,,,percent of total billed charges,,,,,,,,,4418.1,,,percent of total billed charges,,,4712.64,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4565.37,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR EXT ANG LT S ANDI,3253192,CDM,361,RC,36227,CPT,,,,,LT  ,outpatient,facility,,,4909,2061.78,1325.43,4909,,4172.65,,,percent of total billed charges,,,1325.43,,,percent of total billed charges,,,3377.39,,,percent of total billed charges,,,3303.76,,,percent of total billed charges,,,4148.1,,,percent of total billed charges,,,,,,,,,4270.83,,,percent of total billed charges,,,4270.83,,,percent of total billed charges,,,4172.65,,,percent of total billed charges,,,4712.64,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,4418.1,,,percent of total billed charges,,,,,,,,,4565.37,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,,,,,,,4909,,,fee schedule,,,4909,,,fee schedule,,,4909,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,4467.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR EXT ANG RT S ANDI,3253200,CDM,361,RC,36227,CPT,,,,,RT  ,inpatient,facility,,,4909,2061.78,4172.65,4712.64,,4172.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4270.83,,,percent of total billed charges,,,,,,,,,4418.1,,,percent of total billed charges,,,4712.64,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4565.37,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR EXT ANG RT S ANDI,3253200,CDM,361,RC,36227,CPT,,,,,RT  ,outpatient,facility,,,4909,2061.78,1325.43,4909,,4172.65,,,percent of total billed charges,,,1325.43,,,percent of total billed charges,,,3377.39,,,percent of total billed charges,,,3303.76,,,percent of total billed charges,,,4148.1,,,percent of total billed charges,,,,,,,,,4270.83,,,percent of total billed charges,,,4270.83,,,percent of total billed charges,,,4172.65,,,percent of total billed charges,,,4712.64,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,4418.1,,,percent of total billed charges,,,,,,,,,4565.37,,,percent of total billed charges,,,4663.55,,,percent of total billed charges,,,,,,,,,,,,,,,4909,,,fee schedule,,,4909,,,fee schedule,,,4909,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,4467.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR EXT ANG BI S ANDI,3253218,CDM,361,RC,36227,CPT,,,,,50,inpatient,facility,,,7363,3092.46,6258.55,7068.48,,6258.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6405.81,,,percent of total billed charges,,,,,,,,,6626.7,,,percent of total billed charges,,,7068.48,,,percent of total billed charges,,,6994.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6847.59,,,percent of total billed charges,,,6994.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL ART CAR EXT ANG BI S ANDI,3253218,CDM,361,RC,36227,CPT,,,,,50,outpatient,facility,,,7363,3092.46,1988.01,7363,,6258.55,,,percent of total billed charges,,,1988.01,,,percent of total billed charges,,,5065.74,,,percent of total billed charges,,,4955.3,,,percent of total billed charges,,,6221.73,,,percent of total billed charges,,,,,,,,,6405.81,,,percent of total billed charges,,,6405.81,,,percent of total billed charges,,,6258.55,,,percent of total billed charges,,,7068.48,,,percent of total billed charges,,,6994.85,,,percent of total billed charges,,,,,,,,,6626.7,,,percent of total billed charges,,,,,,,,,6847.59,,,percent of total billed charges,,,6994.85,,,percent of total billed charges,,,,,,,,,,,,,,,7363,,,fee schedule,,,7363,,,fee schedule,,,7363,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,6700.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL BR INTRACRN ANG LT S ANDI,3253226,CDM,361,RC,36228,CPT,,,,,LT  ,inpatient,facility,,,2841,1193.22,2414.85,2727.36,,2414.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2471.67,,,percent of total billed charges,,,,,,,,,2556.9,,,percent of total billed charges,,,2727.36,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2642.13,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL BR INTRACRN ANG LT S ANDI,3253226,CDM,361,RC,36228,CPT,,,,,LT  ,outpatient,facility,,,2841,1193.22,767.07,3428,,2414.85,,,percent of total billed charges,,,767.07,,,percent of total billed charges,,,1954.61,,,percent of total billed charges,,,1911.99,,,percent of total billed charges,,,2400.64,,,percent of total billed charges,,,,,,,,,2471.67,,,percent of total billed charges,,,2471.67,,,percent of total billed charges,,,2414.85,,,percent of total billed charges,,,2727.36,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,2556.9,,,percent of total billed charges,,,,,,,,,2642.13,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,,,,,,,2841,,,fee schedule,,,2841,,,fee schedule,,,2841,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2585.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL BR INTRACRN ANG RT S ANDI,3253234,CDM,361,RC,36228,CPT,,,,,RT  ,inpatient,facility,,,2841,1193.22,2414.85,2727.36,,2414.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2471.67,,,percent of total billed charges,,,,,,,,,2556.9,,,percent of total billed charges,,,2727.36,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2642.13,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL BR INTRACRN ANG RT S ANDI,3253234,CDM,361,RC,36228,CPT,,,,,RT  ,outpatient,facility,,,2841,1193.22,767.07,3428,,2414.85,,,percent of total billed charges,,,767.07,,,percent of total billed charges,,,1954.61,,,percent of total billed charges,,,1911.99,,,percent of total billed charges,,,2400.64,,,percent of total billed charges,,,,,,,,,2471.67,,,percent of total billed charges,,,2471.67,,,percent of total billed charges,,,2414.85,,,percent of total billed charges,,,2727.36,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,2556.9,,,percent of total billed charges,,,,,,,,,2642.13,,,percent of total billed charges,,,2698.95,,,percent of total billed charges,,,,,,,,,,,,,,,2841,,,fee schedule,,,2841,,,fee schedule,,,2841,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,2585.31,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL BR INTRACRN ANG BI S ANDI,3253242,CDM,361,RC,36228,CPT,,,,,50,inpatient,facility,,,4261,1789.62,3621.85,4090.56,,3621.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3707.07,,,percent of total billed charges,,,,,,,,,3834.9,,,percent of total billed charges,,,4090.56,,,percent of total billed charges,,,4047.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3962.73,,,percent of total billed charges,,,4047.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC CATH SEL BR INTRACRN ANG BI S ANDI,3253242,CDM,361,RC,36228,CPT,,,,,50,outpatient,facility,,,4261,1789.62,1150.47,4261,,3621.85,,,percent of total billed charges,,,1150.47,,,percent of total billed charges,,,2931.57,,,percent of total billed charges,,,2867.65,,,percent of total billed charges,,,3600.55,,,percent of total billed charges,,,,,,,,,3707.07,,,percent of total billed charges,,,3707.07,,,percent of total billed charges,,,3621.85,,,percent of total billed charges,,,4090.56,,,percent of total billed charges,,,4047.95,,,percent of total billed charges,,,,,,,,,3834.9,,,percent of total billed charges,,,,,,,,,3962.73,,,percent of total billed charges,,,4047.95,,,percent of total billed charges,,,,,,,,,,,,,,,4261,,,fee schedule,,,4261,,,fee schedule,,,4261,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3877.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV PERIPH BRANCH BI,3253283,CDM,361,RC,64640,CPT,,,,,50,inpatient,facility,,,2486,1044.12,2113.1,2386.56,,2113.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2162.82,,,percent of total billed charges,,,,,,,,,2237.4,,,percent of total billed charges,,,2386.56,,,percent of total billed charges,,,2361.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2311.98,,,percent of total billed charges,,,2361.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV PERIPH BRANCH BI,3253283,CDM,361,RC,64640,CPT,,,,,50,outpatient,facility,,,2486,1044.12,671.22,3522,,2113.1,,,percent of total billed charges,,,671.22,,,percent of total billed charges,,,1710.37,,,percent of total billed charges,,,1673.08,,,percent of total billed charges,,,2100.67,,,percent of total billed charges,,,,,,,,,2162.82,,,percent of total billed charges,,,2162.82,,,percent of total billed charges,,,2113.1,,,percent of total billed charges,,,2386.56,,,percent of total billed charges,,,2361.7,,,percent of total billed charges,,,,,,,,,2237.4,,,percent of total billed charges,,,,,,,,,2311.98,,,percent of total billed charges,,,2361.7,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2262.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV PERIPH BRANCH BI,3253283,CDM,361,RC,64640,CPT,5443,APC,,,50,outpatient,facility,,,2486,2486,694.36,2022.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,2022.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1883.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1395.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1395.16,,,fee schedule,,,1395.16,,,fee schedule,,,694.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DST NRV PERIPH BRANCH LT,3253291,CDM,361,RC,64640,CPT,,,,,LT  ,inpatient,facility,,,1658,696.36,1409.3,1591.68,,1409.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.46,,,percent of total billed charges,,,,,,,,,1492.2,,,percent of total billed charges,,,1591.68,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1541.94,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV PERIPH BRANCH LT,3253291,CDM,361,RC,64640,CPT,,,,,LT  ,outpatient,facility,,,1658,696.36,447.66,3522,,1409.3,,,percent of total billed charges,,,447.66,,,percent of total billed charges,,,1140.7,,,percent of total billed charges,,,1115.83,,,percent of total billed charges,,,1401.01,,,percent of total billed charges,,,,,,,,,1442.46,,,percent of total billed charges,,,1442.46,,,percent of total billed charges,,,1409.3,,,percent of total billed charges,,,1591.68,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,1492.2,,,percent of total billed charges,,,,,,,,,1541.94,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1508.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV PERIPH BRANCH LT,3253291,CDM,361,RC,64640,CPT,5443,APC,,,LT  ,outpatient,facility,,,1658,1658,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DST NRV PERIPH BRANCH RT,3253309,CDM,361,RC,64640,CPT,,,,,RT  ,inpatient,facility,,,1658,696.36,1409.3,1591.68,,1409.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.46,,,percent of total billed charges,,,,,,,,,1492.2,,,percent of total billed charges,,,1591.68,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1541.94,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DST NRV PERIPH BRANCH RT,3253309,CDM,361,RC,64640,CPT,,,,,RT  ,outpatient,facility,,,1658,696.36,447.66,3522,,1409.3,,,percent of total billed charges,,,447.66,,,percent of total billed charges,,,1140.7,,,percent of total billed charges,,,1115.83,,,percent of total billed charges,,,1401.01,,,percent of total billed charges,,,,,,,,,1442.46,,,percent of total billed charges,,,1442.46,,,percent of total billed charges,,,1409.3,,,percent of total billed charges,,,1591.68,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,1492.2,,,percent of total billed charges,,,,,,,,,1541.94,,,percent of total billed charges,,,1575.1,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1508.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DST NRV PERIPH BRANCH RT,3253309,CDM,361,RC,64640,CPT,5443,APC,,,RT  ,outpatient,facility,,,1658,1658,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT S ART OPEN PERC INIT S ANDI,3253358,CDM,361,RC,37236,CPT,,,,,,inpatient,facility,,,14473,6078.66,12302.05,13894.08,,12302.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12591.51,,,percent of total billed charges,,,,,,,,,13025.7,,,percent of total billed charges,,,13894.08,,,percent of total billed charges,,,13749.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13459.89,,,percent of total billed charges,,,13749.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S ART OPEN PERC INIT S ANDI,3253358,CDM,361,RC,37236,CPT,,,,,,outpatient,facility,,,14473,6078.66,3907.71,29580,,12302.05,,,percent of total billed charges,,,3907.71,,,percent of total billed charges,,,9957.42,,,percent of total billed charges,,,9740.33,,,percent of total billed charges,,,12229.68,,,percent of total billed charges,,,,,,,,,12591.51,,,percent of total billed charges,,,12591.51,,,percent of total billed charges,,,12302.05,,,percent of total billed charges,,,13894.08,,,percent of total billed charges,,,13749.35,,,percent of total billed charges,,,,,,,,,13025.7,,,percent of total billed charges,,,,,,,,,13459.89,,,percent of total billed charges,,,13749.35,,,percent of total billed charges,,,,,,,,,,,,,,,14473,,,fee schedule,,,14473,,,fee schedule,,,14473,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,13170.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT S ART OPEN PERC INIT S ANDI,3253358,CDM,361,RC,37236,CPT,5193,APC,,,,outpatient,facility,,,14473,14473,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT S ART OPEN PERC ADDL S ANDI,3253366,CDM,361,RC,37237,CPT,,,,,,inpatient,facility,,,6947,2917.74,5904.95,6669.12,,5904.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6043.89,,,percent of total billed charges,,,,,,,,,6252.3,,,percent of total billed charges,,,6669.12,,,percent of total billed charges,,,6599.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6460.71,,,percent of total billed charges,,,6599.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S ART OPEN PERC ADDL S ANDI,3253366,CDM,361,RC,37237,CPT,,,,,,outpatient,facility,,,6947,2917.74,1875.69,28046,,5904.95,,,percent of total billed charges,,,1875.69,,,percent of total billed charges,,,4779.54,,,percent of total billed charges,,,4675.33,,,percent of total billed charges,,,5870.22,,,percent of total billed charges,,,,,,,,,6043.89,,,percent of total billed charges,,,6043.89,,,percent of total billed charges,,,5904.95,,,percent of total billed charges,,,6669.12,,,percent of total billed charges,,,6599.65,,,percent of total billed charges,,,,,,,,,6252.3,,,percent of total billed charges,,,,,,,,,6460.71,,,percent of total billed charges,,,6599.65,,,percent of total billed charges,,,,,,,,,,,,,,,6947,,,fee schedule,,,6947,,,fee schedule,,,6947,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,6321.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT S VEIN OPEN PERC INIT S ANDI,3253374,CDM,361,RC,37238,CPT,,,,,,inpatient,facility,,,14519,6097.98,12341.15,13938.24,,12341.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12631.53,,,percent of total billed charges,,,,,,,,,13067.1,,,percent of total billed charges,,,13938.24,,,percent of total billed charges,,,13793.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13502.67,,,percent of total billed charges,,,13793.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S VEIN OPEN PERC INIT S ANDI,3253374,CDM,361,RC,37238,CPT,,,,,,outpatient,facility,,,14519,6097.98,3920.13,29580,,12341.15,,,percent of total billed charges,,,3920.13,,,percent of total billed charges,,,9989.07,,,percent of total billed charges,,,9771.29,,,percent of total billed charges,,,12268.56,,,percent of total billed charges,,,,,,,,,12631.53,,,percent of total billed charges,,,12631.53,,,percent of total billed charges,,,12341.15,,,percent of total billed charges,,,13938.24,,,percent of total billed charges,,,13793.05,,,percent of total billed charges,,,,,,,,,13067.1,,,percent of total billed charges,,,,,,,,,13502.67,,,percent of total billed charges,,,13793.05,,,percent of total billed charges,,,,,,,,,,,,,,,14519,,,fee schedule,,,14519,,,fee schedule,,,14519,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,13212.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT S VEIN OPEN PERC INIT S ANDI,3253374,CDM,361,RC,37238,CPT,5193,APC,,,,outpatient,facility,,,14519,14519,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT S VEIN OPEN PERC ADDL S ANDI,3253382,CDM,361,RC,37239,CPT,,,,,,inpatient,facility,,,7260,3049.2,6171,6969.6,,6171,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6316.2,,,percent of total billed charges,,,,,,,,,6534,,,percent of total billed charges,,,6969.6,,,percent of total billed charges,,,6897,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6751.8,,,percent of total billed charges,,,6897,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S VEIN OPEN PERC ADDL S ANDI,3253382,CDM,361,RC,37239,CPT,,,,,,outpatient,facility,,,7260,3049.2,1960.2,28046,,6171,,,percent of total billed charges,,,1960.2,,,percent of total billed charges,,,4994.88,,,percent of total billed charges,,,4885.98,,,percent of total billed charges,,,6134.7,,,percent of total billed charges,,,,,,,,,6316.2,,,percent of total billed charges,,,6316.2,,,percent of total billed charges,,,6171,,,percent of total billed charges,,,6969.6,,,percent of total billed charges,,,6897,,,percent of total billed charges,,,,,,,,,6534,,,percent of total billed charges,,,,,,,,,6751.8,,,percent of total billed charges,,,6897,,,percent of total billed charges,,,,,,,,,,,,,,,7260,,,fee schedule,,,7260,,,fee schedule,,,7260,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,6606.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC VENOUS S ANDI,3253390,CDM,361,RC,37241,CPT,,,,,,inpatient,facility,,,14440,6064.8,12274,13862.4,,12274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12562.8,,,percent of total billed charges,,,,,,,,,12996,,,percent of total billed charges,,,13862.4,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13429.2,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC VENOUS S ANDI,3253390,CDM,361,RC,37241,CPT,,,,,,outpatient,facility,,,14440,6064.8,3898.8,29580,,12274,,,percent of total billed charges,,,3898.8,,,percent of total billed charges,,,9934.72,,,percent of total billed charges,,,9718.12,,,percent of total billed charges,,,12201.8,,,percent of total billed charges,,,,,,,,,12562.8,,,percent of total billed charges,,,12562.8,,,percent of total billed charges,,,12274,,,percent of total billed charges,,,13862.4,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,12996,,,percent of total billed charges,,,,,,,,,13429.2,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,,,,,,,14440,,,fee schedule,,,14440,,,fee schedule,,,14440,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,13140.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC VENOUS S ANDI,3253390,CDM,361,RC,37241,CPT,5193,APC,,,,outpatient,facility,,,14440,14440,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EMB OCCL VASC ARTERIAL S ANDI,3253408,CDM,361,RC,37242,CPT,,,,,,inpatient,facility,,,14665,6159.3,12465.25,14078.4,,12465.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12758.55,,,percent of total billed charges,,,,,,,,,13198.5,,,percent of total billed charges,,,14078.4,,,percent of total billed charges,,,13931.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13638.45,,,percent of total billed charges,,,13931.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC ARTERIAL S ANDI,3253408,CDM,361,RC,37242,CPT,,,,,,outpatient,facility,,,14665,6159.3,3959.55,29580,,12465.25,,,percent of total billed charges,,,3959.55,,,percent of total billed charges,,,10089.52,,,percent of total billed charges,,,9869.54,,,percent of total billed charges,,,12391.92,,,percent of total billed charges,,,,,,,,,12758.55,,,percent of total billed charges,,,12758.55,,,percent of total billed charges,,,12465.25,,,percent of total billed charges,,,14078.4,,,percent of total billed charges,,,13931.75,,,percent of total billed charges,,,,,,,,,13198.5,,,percent of total billed charges,,,,,,,,,13638.45,,,percent of total billed charges,,,13931.75,,,percent of total billed charges,,,,,,,,,,,,,,,14665,,,fee schedule,,,14665,,,fee schedule,,,14665,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,13345.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC ARTERIAL S ANDI,3253408,CDM,361,RC,37242,CPT,5194,APC,,,,outpatient,facility,,,14665,14665,9330.92,25945.62,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,18251.4,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17893.53,,,fee schedule,,,,,,,,,,,,,,,25945.62,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",24156.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17893.53,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17893.53,,,fee schedule,,,17893.53,,,fee schedule,,,9330.92,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EMB OCCL VASC TMRS ORG S ANDI,3253416,CDM,361,RC,37243,CPT,,,,,,inpatient,facility,,,15906,6680.52,13520.1,15269.76,,13520.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13838.22,,,percent of total billed charges,,,,,,,,,14315.4,,,percent of total billed charges,,,15269.76,,,percent of total billed charges,,,15110.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14792.58,,,percent of total billed charges,,,15110.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC TMRS ORG S ANDI,3253416,CDM,361,RC,37243,CPT,,,,,,outpatient,facility,,,15906,6680.52,4294.62,29580,,13520.1,,,percent of total billed charges,,,4294.62,,,percent of total billed charges,,,10943.33,,,percent of total billed charges,,,10704.74,,,percent of total billed charges,,,13440.57,,,percent of total billed charges,,,,,,,,,13838.22,,,percent of total billed charges,,,13838.22,,,percent of total billed charges,,,13520.1,,,percent of total billed charges,,,15269.76,,,percent of total billed charges,,,15110.7,,,percent of total billed charges,,,,,,,,,14315.4,,,percent of total billed charges,,,,,,,,,14792.58,,,percent of total billed charges,,,15110.7,,,percent of total billed charges,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,11001.5,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,14474.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC TMRS ORG S ANDI,3253416,CDM,361,RC,37243,CPT,5193,APC,,,,outpatient,facility,,,15906,15906,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EMB OCCL VASC HEMORRHAGE S ANDI,3253424,CDM,361,RC,37244,CPT,,,,,,inpatient,facility,,,14440,6064.8,12274,13862.4,,12274,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,12562.8,,,percent of total billed charges,,,,,,,,,12996,,,percent of total billed charges,,,13862.4,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,13429.2,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC HEMORRHAGE S ANDI,3253424,CDM,361,RC,37244,CPT,,,,,,outpatient,facility,,,14440,6064.8,3898.8,29580,,12274,,,percent of total billed charges,,,3898.8,,,percent of total billed charges,,,9934.72,,,percent of total billed charges,,,9718.12,,,percent of total billed charges,,,12201.8,,,percent of total billed charges,,,,,,,,,12562.8,,,percent of total billed charges,,,12562.8,,,percent of total billed charges,,,12274,,,percent of total billed charges,,,13862.4,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,12996,,,percent of total billed charges,,,,,,,,,13429.2,,,percent of total billed charges,,,13718,,,percent of total billed charges,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,11001.5,,,fee schedule,,,,,,,,,29580,,,percent of total billed charges,,,13140.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EMB OCCL VASC HEMORRHAGE S ANDI,3253424,CDM,361,RC,37244,CPT,5193,APC,,,,outpatient,facility,,,14440,14440,5766.27,16277.73,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11450.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,11226.02,,,fee schedule,,,,,,,,,,,,,,,16277.73,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",15155.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,11226.02,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,11226.02,,,fee schedule,,,11226.02,,,fee schedule,,,5766.27,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN CATH FLUID VISCERAL IMG GD,3253432,CDM,361,RC,49405,CPT,,,,,,inpatient,facility,,,2535,1064.7,2154.75,2433.6,,2154.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2205.45,,,percent of total billed charges,,,,,,,,,2281.5,,,percent of total billed charges,,,2433.6,,,percent of total billed charges,,,2408.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2357.55,,,percent of total billed charges,,,2408.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID VISCERAL IMG GD,3253432,CDM,361,RC,49405,CPT,,,,,,outpatient,facility,,,2535,1064.7,684.45,5933,,2154.75,,,percent of total billed charges,,,684.45,,,percent of total billed charges,,,1744.08,,,percent of total billed charges,,,1706.05,,,percent of total billed charges,,,2142.07,,,percent of total billed charges,,,,,,,,,2205.45,,,percent of total billed charges,,,2205.45,,,percent of total billed charges,,,2154.75,,,percent of total billed charges,,,2433.6,,,percent of total billed charges,,,2408.25,,,percent of total billed charges,,,,,,,,,2281.5,,,percent of total billed charges,,,,,,,,,2357.55,,,percent of total billed charges,,,2408.25,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2306.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID VISCERAL IMG GD,3253432,CDM,361,RC,49405,CPT,5072,APC,,,,outpatient,facility,,,2535,2535,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN CATH FLUID PERI PERC IMG GD,3253440,CDM,361,RC,49406,CPT,,,,,,inpatient,facility,,,2777,1166.34,2360.45,2665.92,,2360.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2415.99,,,percent of total billed charges,,,,,,,,,2499.3,,,percent of total billed charges,,,2665.92,,,percent of total billed charges,,,2638.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2582.61,,,percent of total billed charges,,,2638.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID PERI PERC IMG GD,3253440,CDM,361,RC,49406,CPT,,,,,,outpatient,facility,,,2777,1166.34,749.79,5933,,2360.45,,,percent of total billed charges,,,749.79,,,percent of total billed charges,,,1910.58,,,percent of total billed charges,,,1868.92,,,percent of total billed charges,,,2346.57,,,percent of total billed charges,,,,,,,,,2415.99,,,percent of total billed charges,,,2415.99,,,percent of total billed charges,,,2360.45,,,percent of total billed charges,,,2665.92,,,percent of total billed charges,,,2638.15,,,percent of total billed charges,,,,,,,,,2499.3,,,percent of total billed charges,,,,,,,,,2582.61,,,percent of total billed charges,,,2638.15,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2527.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID PERI PERC IMG GD,3253440,CDM,361,RC,49406,CPT,5072,APC,,,,outpatient,facility,,,2777,2777,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN CATH FLUID TRNSVAG REC IMG GD,3253457,CDM,361,RC,49407,CPT,,,,,,inpatient,facility,,,2528,1061.76,2148.8,2426.88,,2148.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2199.36,,,percent of total billed charges,,,,,,,,,2275.2,,,percent of total billed charges,,,2426.88,,,percent of total billed charges,,,2401.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2351.04,,,percent of total billed charges,,,2401.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID TRNSVAG REC IMG GD,3253457,CDM,361,RC,49407,CPT,,,,,,outpatient,facility,,,2528,1061.76,682.56,5933,,2148.8,,,percent of total billed charges,,,682.56,,,percent of total billed charges,,,1739.26,,,percent of total billed charges,,,1701.34,,,percent of total billed charges,,,2136.16,,,percent of total billed charges,,,,,,,,,2199.36,,,percent of total billed charges,,,2199.36,,,percent of total billed charges,,,2148.8,,,percent of total billed charges,,,2426.88,,,percent of total billed charges,,,2401.6,,,percent of total billed charges,,,,,,,,,2275.2,,,percent of total billed charges,,,,,,,,,2351.04,,,percent of total billed charges,,,2401.6,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2300.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID TRNSVAG REC IMG GD,3253457,CDM,361,RC,49407,CPT,5072,APC,,,,outpatient,facility,,,2528,2528,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN CATH FLUID TISSUE SOFT IMG GD,3253465,CDM,361,RC,10030,CPT,,,,,,inpatient,facility,,,1734,728.28,1473.9,1664.64,,1473.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1508.58,,,percent of total billed charges,,,,,,,,,1560.6,,,percent of total billed charges,,,1664.64,,,percent of total billed charges,,,1647.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1612.62,,,percent of total billed charges,,,1647.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID TISSUE SOFT IMG GD,3253465,CDM,361,RC,10030,CPT,,,,,,outpatient,facility,,,1734,728.28,468.18,3522,,1473.9,,,percent of total billed charges,,,468.18,,,percent of total billed charges,,,1192.99,,,percent of total billed charges,,,1166.98,,,percent of total billed charges,,,1465.23,,,percent of total billed charges,,,,,,,,,1508.58,,,percent of total billed charges,,,1508.58,,,percent of total billed charges,,,1473.9,,,percent of total billed charges,,,1664.64,,,percent of total billed charges,,,1647.3,,,percent of total billed charges,,,,,,,,,1560.6,,,percent of total billed charges,,,,,,,,,1612.62,,,percent of total billed charges,,,1647.3,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1577.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN CATH FLUID TISSUE SOFT IMG GD,3253465,CDM,361,RC,10030,CPT,5071,APC,,,,outpatient,facility,,,1734,1734,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ PSEUDOANEURYSM EXT BI,3253523,CDM,361,RC,36002,CPT,,,,,50,inpatient,facility,,,854,358.68,725.9,819.84,,725.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.98,,,percent of total billed charges,,,,,,,,,768.6,,,percent of total billed charges,,,819.84,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,794.22,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ PSEUDOANEURYSM EXT BI,3253523,CDM,361,RC,36002,CPT,,,,,50,outpatient,facility,,,854,358.68,230.58,3522,,725.9,,,percent of total billed charges,,,230.58,,,percent of total billed charges,,,587.55,,,percent of total billed charges,,,574.74,,,percent of total billed charges,,,721.63,,,percent of total billed charges,,,,,,,,,742.98,,,percent of total billed charges,,,742.98,,,percent of total billed charges,,,725.9,,,percent of total billed charges,,,819.84,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,768.6,,,percent of total billed charges,,,,,,,,,794.22,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,,,,,,,961.58,,,fee schedule,,,961.58,,,fee schedule,,,942.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,777.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ PSEUDOANEURYSM EXT BI,3253523,CDM,361,RC,36002,CPT,5181,APC,,,50,outpatient,facility,,,854,854,471.37,1394.28,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,961.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,980.8,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,961.57,,,fee schedule,,,,,,,,,,,,,,,1394.28,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1298.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,961.57,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,961.57,,,fee schedule,,,961.57,,,fee schedule,,,471.37,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX BRST W WO DEV IMG SG LSN 1ST LT,3253606,CDM,361,RC,19081,CPT,,,,,LT  ,inpatient,facility,,,3643,1530.06,3096.55,3497.28,,3096.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3169.41,,,percent of total billed charges,,,,,,,,,3278.7,,,percent of total billed charges,,,3497.28,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3387.99,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX BRST W WO DEV IMG SG LSN 1ST LT,3253606,CDM,361,RC,19081,CPT,,,,,LT  ,outpatient,facility,,,3643,1530.06,983.61,5933,,3096.55,,,percent of total billed charges,,,983.61,,,percent of total billed charges,,,2506.38,,,percent of total billed charges,,,2451.74,,,percent of total billed charges,,,3078.34,,,percent of total billed charges,,,,,,,,,3169.41,,,percent of total billed charges,,,3169.41,,,percent of total billed charges,,,3096.55,,,percent of total billed charges,,,3497.28,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,3278.7,,,percent of total billed charges,,,,,,,,,3387.99,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,3315.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX BRST W WO DEV IMG SG LSN 1ST LT,3253606,CDM,361,RC,19081,CPT,5072,APC,,,LT  ,outpatient,facility,,,3643,3643,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX BRST W WO DEV IMG SG LSN 1ST RT,3253614,CDM,361,RC,19081,CPT,,,,,RT  ,inpatient,facility,,,3643,1530.06,3096.55,3497.28,,3096.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3169.41,,,percent of total billed charges,,,,,,,,,3278.7,,,percent of total billed charges,,,3497.28,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3387.99,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX BRST W WO DEV IMG SG LSN 1ST RT,3253614,CDM,361,RC,19081,CPT,,,,,RT  ,outpatient,facility,,,3643,1530.06,983.61,5933,,3096.55,,,percent of total billed charges,,,983.61,,,percent of total billed charges,,,2506.38,,,percent of total billed charges,,,2451.74,,,percent of total billed charges,,,3078.34,,,percent of total billed charges,,,,,,,,,3169.41,,,percent of total billed charges,,,3169.41,,,percent of total billed charges,,,3096.55,,,percent of total billed charges,,,3497.28,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,3278.7,,,percent of total billed charges,,,,,,,,,3387.99,,,percent of total billed charges,,,3460.85,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,3315.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX BRST W WO DEV IMG SG LSN 1ST RT,3253614,CDM,361,RC,19081,CPT,5072,APC,,,RT  ,outpatient,facility,,,3643,3643,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX BRST W WO DEV IMG SG LSN ADD,3253655,CDM,361,RC,19082,CPT,,,,,,inpatient,facility,,,1822,765.24,1548.7,1749.12,,1548.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1585.14,,,percent of total billed charges,,,,,,,,,1639.8,,,percent of total billed charges,,,1749.12,,,percent of total billed charges,,,1730.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1694.46,,,percent of total billed charges,,,1730.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX BRST W WO DEV IMG SG LSN ADD,3253655,CDM,361,RC,19082,CPT,,,,,,outpatient,facility,,,1822,765.24,491.94,3428,,1548.7,,,percent of total billed charges,,,491.94,,,percent of total billed charges,,,1253.54,,,percent of total billed charges,,,1226.21,,,percent of total billed charges,,,1539.59,,,percent of total billed charges,,,,,,,,,1585.14,,,percent of total billed charges,,,1585.14,,,percent of total billed charges,,,1548.7,,,percent of total billed charges,,,1749.12,,,percent of total billed charges,,,1730.9,,,percent of total billed charges,,,,,,,,,1639.8,,,percent of total billed charges,,,,,,,,,1694.46,,,percent of total billed charges,,,1730.9,,,percent of total billed charges,,,,,,,,,,,,,,,1822,,,fee schedule,,,1822,,,fee schedule,,,1822,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1658.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC DEV S BRST MAMMO GD LSN ADD,3253671,CDM,361,RC,19282,CPT,,,,,,inpatient,facility,,,725,304.5,616.25,696,,616.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,630.75,,,percent of total billed charges,,,,,,,,,652.5,,,percent of total billed charges,,,696,,,percent of total billed charges,,,688.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,674.25,,,percent of total billed charges,,,688.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC DEV S BRST MAMMO GD LSN ADD,3253671,CDM,361,RC,19282,CPT,,,,,,outpatient,facility,,,725,304.5,195.75,3428,,616.25,,,percent of total billed charges,,,195.75,,,percent of total billed charges,,,498.8,,,percent of total billed charges,,,487.92,,,percent of total billed charges,,,612.63,,,percent of total billed charges,,,,,,,,,630.75,,,percent of total billed charges,,,630.75,,,percent of total billed charges,,,616.25,,,percent of total billed charges,,,696,,,percent of total billed charges,,,688.75,,,percent of total billed charges,,,,,,,,,652.5,,,percent of total billed charges,,,,,,,,,674.25,,,percent of total billed charges,,,688.75,,,percent of total billed charges,,,,,,,,,,,,,,,725,,,fee schedule,,,725,,,fee schedule,,,725,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,659.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DUCTO GALACTOGRAM MAMMARY SGL RTS ANDI,3253739,CDM,320,RC,77053,CPT,,,,,RT  ,inpatient,facility,,,419,175.98,356.15,402.24,,356.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.53,,,percent of total billed charges,,,,,,,,,377.1,,,percent of total billed charges,,,402.24,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,389.67,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DUCTO GALACTOGRAM MAMMARY SGL RTS ANDI,3253739,CDM,320,RC,77053,CPT,,,,,RT  ,outpatient,facility,,,419,175.98,113.13,402.24,,356.15,,,percent of total billed charges,,,113.13,,,percent of total billed charges,,,288.27,,,percent of total billed charges,,,281.99,,,percent of total billed charges,,,354.06,,,percent of total billed charges,,,,,,,,,364.53,,,percent of total billed charges,,,364.53,,,percent of total billed charges,,,356.15,,,percent of total billed charges,,,402.24,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,377.1,,,percent of total billed charges,,,,,,,,,389.67,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,327.24,,,percent of total billed charges,,,381.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DUCTO GALACTOGRAM MAMMARY SGL RTS ANDI,3253739,CDM,320,RC,77053,CPT,5523,APC,,,RT  ,outpatient,facility,,,419,419,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DUCTO GALACTOGRAM MAMMARY SGL LTS ANDI,3253754,CDM,320,RC,77053,CPT,,,,,LT  ,inpatient,facility,,,419,175.98,356.15,402.24,,356.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,364.53,,,percent of total billed charges,,,,,,,,,377.1,,,percent of total billed charges,,,402.24,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,389.67,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DUCTO GALACTOGRAM MAMMARY SGL LTS ANDI,3253754,CDM,320,RC,77053,CPT,,,,,LT  ,outpatient,facility,,,419,175.98,113.13,402.24,,356.15,,,percent of total billed charges,,,113.13,,,percent of total billed charges,,,288.27,,,percent of total billed charges,,,281.99,,,percent of total billed charges,,,354.06,,,percent of total billed charges,,,,,,,,,364.53,,,percent of total billed charges,,,364.53,,,percent of total billed charges,,,356.15,,,percent of total billed charges,,,402.24,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,377.1,,,percent of total billed charges,,,,,,,,,389.67,,,percent of total billed charges,,,398.05,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,327.24,,,percent of total billed charges,,,381.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DUCTO GALACTOGRAM MAMMARY SGL LTS ANDI,3253754,CDM,320,RC,77053,CPT,5523,APC,,,LT  ,outpatient,facility,,,419,419,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DUCTO GALACTOGRAM MAMMARY MULTI S ANDI,3253770,CDM,320,RC,77054,CPT,,,,,,inpatient,facility,,,551,231.42,468.35,528.96,,468.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,479.37,,,percent of total billed charges,,,,,,,,,495.9,,,percent of total billed charges,,,528.96,,,percent of total billed charges,,,523.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,512.43,,,percent of total billed charges,,,523.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DUCTO GALACTOGRAM MAMMARY MULTI S ANDI,3253770,CDM,320,RC,77054,CPT,,,,,,outpatient,facility,,,551,231.42,148.77,528.96,,468.35,,,percent of total billed charges,,,148.77,,,percent of total billed charges,,,379.09,,,percent of total billed charges,,,370.82,,,percent of total billed charges,,,465.59,,,percent of total billed charges,,,,,,,,,479.37,,,percent of total billed charges,,,479.37,,,percent of total billed charges,,,468.35,,,percent of total billed charges,,,528.96,,,percent of total billed charges,,,523.45,,,percent of total billed charges,,,,,,,,,495.9,,,percent of total billed charges,,,,,,,,,512.43,,,percent of total billed charges,,,523.45,,,percent of total billed charges,,,,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,245.05,,,fee schedule,,,,,,,,,430.33,,,percent of total billed charges,,,501.41,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DUCTO GALACTOGRAM MAMMARY MULTI S ANDI,3253770,CDM,320,RC,77054,CPT,5523,APC,,,,outpatient,facility,,,551,551,126.85,362.57,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,255.05,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,250.05,,,fee schedule,,,,,,,,,,,,,,,362.57,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",337.57,,,fee schedule,,,,,,,,,,,,,,,,,,,,,250.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,250.05,,,fee schedule,,,250.05,,,fee schedule,,,126.85,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC DEV S BRST MAMMO GD LSN 1ST LT,3253903,CDM,361,RC,19281,CPT,,,,,LT  ,inpatient,facility,,,1449,608.58,1231.65,1391.04,,1231.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1260.63,,,percent of total billed charges,,,,,,,,,1304.1,,,percent of total billed charges,,,1391.04,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1347.57,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC DEV S BRST MAMMO GD LSN 1ST LT,3253903,CDM,361,RC,19281,CPT,,,,,LT  ,outpatient,facility,,,1449,608.58,391.23,5933,,1231.65,,,percent of total billed charges,,,391.23,,,percent of total billed charges,,,996.91,,,percent of total billed charges,,,975.18,,,percent of total billed charges,,,1224.4,,,percent of total billed charges,,,,,,,,,1260.63,,,percent of total billed charges,,,1260.63,,,percent of total billed charges,,,1231.65,,,percent of total billed charges,,,1391.04,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,1304.1,,,percent of total billed charges,,,,,,,,,1347.57,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,,,,,,,1449,,,fee schedule,,,1449,,,fee schedule,,,1449,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1318.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC DEV S BRST MAMMO GD LSN 1ST LT,3253903,CDM,361,RC,19281,CPT,5072,APC,,,LT  ,outpatient,facility,,,1449,1449,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC DEV S BRST MAMMO GD LSN 1ST RT,3253911,CDM,361,RC,19281,CPT,,,,,RT  ,inpatient,facility,,,1449,608.58,1231.65,1391.04,,1231.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1260.63,,,percent of total billed charges,,,,,,,,,1304.1,,,percent of total billed charges,,,1391.04,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1347.57,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC DEV S BRST MAMMO GD LSN 1ST RT,3253911,CDM,361,RC,19281,CPT,,,,,RT  ,outpatient,facility,,,1449,608.58,391.23,5933,,1231.65,,,percent of total billed charges,,,391.23,,,percent of total billed charges,,,996.91,,,percent of total billed charges,,,975.18,,,percent of total billed charges,,,1224.4,,,percent of total billed charges,,,,,,,,,1260.63,,,percent of total billed charges,,,1260.63,,,percent of total billed charges,,,1231.65,,,percent of total billed charges,,,1391.04,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,1304.1,,,percent of total billed charges,,,,,,,,,1347.57,,,percent of total billed charges,,,1376.55,,,percent of total billed charges,,,,,,,,,,,,,,,1449,,,fee schedule,,,1449,,,fee schedule,,,1449,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1318.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC DEV S BRST MAMMO GD LSN 1ST RT,3253911,CDM,361,RC,19281,CPT,5072,APC,,,RT  ,outpatient,facility,,,1449,1449,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ MYELOGRAM AND CT LUMBAR,3254257,CDM,361,RC,62284,CPT,,,,,,inpatient,facility,,,886,372.12,753.1,850.56,,753.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,770.82,,,percent of total billed charges,,,,,,,,,797.4,,,percent of total billed charges,,,850.56,,,percent of total billed charges,,,841.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,823.98,,,percent of total billed charges,,,841.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ MYELOGRAM AND CT LUMBAR,3254257,CDM,361,RC,62284,CPT,,,,,,outpatient,facility,,,886,372.12,239.22,3428,,753.1,,,percent of total billed charges,,,239.22,,,percent of total billed charges,,,609.57,,,percent of total billed charges,,,596.28,,,percent of total billed charges,,,748.67,,,percent of total billed charges,,,,,,,,,770.82,,,percent of total billed charges,,,770.82,,,percent of total billed charges,,,753.1,,,percent of total billed charges,,,850.56,,,percent of total billed charges,,,841.7,,,percent of total billed charges,,,,,,,,,797.4,,,percent of total billed charges,,,,,,,,,823.98,,,percent of total billed charges,,,841.7,,,percent of total billed charges,,,,,,,,,,,,,,,886,,,fee schedule,,,886,,,fee schedule,,,886,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,806.26,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM WO US GD LT,3261989,CDM,361,RC,20600,CPT,,,,,LT  ,inpatient,facility,,,444,186.48,377.4,426.24,,377.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.28,,,percent of total billed charges,,,,,,,,,399.6,,,percent of total billed charges,,,426.24,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,412.92,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM WO US GD LT,3261989,CDM,361,RC,20600,CPT,,,,,LT  ,outpatient,facility,,,444,186.48,119.88,3428,,377.4,,,percent of total billed charges,,,119.88,,,percent of total billed charges,,,305.47,,,percent of total billed charges,,,298.81,,,percent of total billed charges,,,375.18,,,percent of total billed charges,,,,,,,,,386.28,,,percent of total billed charges,,,386.28,,,percent of total billed charges,,,377.4,,,percent of total billed charges,,,426.24,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,399.6,,,percent of total billed charges,,,,,,,,,412.92,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,404.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM WO US GD LT,3261989,CDM,361,RC,20600,CPT,5441,APC,,,LT  ,outpatient,facility,,,444,444,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR SM WO US GD RT,3261997,CDM,361,RC,20600,CPT,,,,,RT  ,inpatient,facility,,,444,186.48,377.4,426.24,,377.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,386.28,,,percent of total billed charges,,,,,,,,,399.6,,,percent of total billed charges,,,426.24,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,412.92,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM WO US GD RT,3261997,CDM,361,RC,20600,CPT,,,,,RT  ,outpatient,facility,,,444,186.48,119.88,3428,,377.4,,,percent of total billed charges,,,119.88,,,percent of total billed charges,,,305.47,,,percent of total billed charges,,,298.81,,,percent of total billed charges,,,375.18,,,percent of total billed charges,,,,,,,,,386.28,,,percent of total billed charges,,,386.28,,,percent of total billed charges,,,377.4,,,percent of total billed charges,,,426.24,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,399.6,,,percent of total billed charges,,,,,,,,,412.92,,,percent of total billed charges,,,421.8,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,404.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM WO US GD RT,3261997,CDM,361,RC,20600,CPT,5441,APC,,,RT  ,outpatient,facility,,,444,444,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR SM WO US GD BI,3262003,CDM,361,RC,20600,CPT,,,,,50,inpatient,facility,,,644,270.48,547.4,618.24,,547.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,560.28,,,percent of total billed charges,,,,,,,,,579.6,,,percent of total billed charges,,,618.24,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,598.92,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM WO US GD BI,3262003,CDM,361,RC,20600,CPT,,,,,50,outpatient,facility,,,644,270.48,173.88,3428,,547.4,,,percent of total billed charges,,,173.88,,,percent of total billed charges,,,443.07,,,percent of total billed charges,,,433.41,,,percent of total billed charges,,,544.18,,,percent of total billed charges,,,,,,,,,560.28,,,percent of total billed charges,,,560.28,,,percent of total billed charges,,,547.4,,,percent of total billed charges,,,618.24,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,,,,,,,579.6,,,percent of total billed charges,,,,,,,,,598.92,,,percent of total billed charges,,,611.8,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,586.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM WO US GD BI,3262003,CDM,361,RC,20600,CPT,5441,APC,,,50,outpatient,facility,,,644,644,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR INTR WO US GD RT,3262011,CDM,361,RC,20605,CPT,,,,,RT  ,inpatient,facility,,,461,193.62,391.85,442.56,,391.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.07,,,percent of total billed charges,,,,,,,,,414.9,,,percent of total billed charges,,,442.56,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.73,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR WO US GD RT,3262011,CDM,361,RC,20605,CPT,,,,,RT  ,outpatient,facility,,,461,193.62,124.47,3428,,391.85,,,percent of total billed charges,,,124.47,,,percent of total billed charges,,,317.17,,,percent of total billed charges,,,310.25,,,percent of total billed charges,,,389.55,,,percent of total billed charges,,,,,,,,,401.07,,,percent of total billed charges,,,401.07,,,percent of total billed charges,,,391.85,,,percent of total billed charges,,,442.56,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,414.9,,,percent of total billed charges,,,,,,,,,428.73,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,419.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR WO US GD RT,3262011,CDM,361,RC,20605,CPT,5441,APC,,,RT  ,outpatient,facility,,,461,461,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR INTR WO US GD BI,3262029,CDM,361,RC,20605,CPT,,,,,50,inpatient,facility,,,692,290.64,588.2,664.32,,588.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,602.04,,,percent of total billed charges,,,,,,,,,622.8,,,percent of total billed charges,,,664.32,,,percent of total billed charges,,,657.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,643.56,,,percent of total billed charges,,,657.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR WO US GD BI,3262029,CDM,361,RC,20605,CPT,,,,,50,outpatient,facility,,,692,290.64,186.84,3428,,588.2,,,percent of total billed charges,,,186.84,,,percent of total billed charges,,,476.1,,,percent of total billed charges,,,465.72,,,percent of total billed charges,,,584.74,,,percent of total billed charges,,,,,,,,,602.04,,,percent of total billed charges,,,602.04,,,percent of total billed charges,,,588.2,,,percent of total billed charges,,,664.32,,,percent of total billed charges,,,657.4,,,percent of total billed charges,,,,,,,,,622.8,,,percent of total billed charges,,,,,,,,,643.56,,,percent of total billed charges,,,657.4,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,629.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR WO US GD BI,3262029,CDM,361,RC,20605,CPT,5441,APC,,,50,outpatient,facility,,,692,692,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR INTR WO US GD LT,3262037,CDM,361,RC,20605,CPT,,,,,LT  ,inpatient,facility,,,461,193.62,391.85,442.56,,391.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,401.07,,,percent of total billed charges,,,,,,,,,414.9,,,percent of total billed charges,,,442.56,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,428.73,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR WO US GD LT,3262037,CDM,361,RC,20605,CPT,,,,,LT  ,outpatient,facility,,,461,193.62,124.47,3428,,391.85,,,percent of total billed charges,,,124.47,,,percent of total billed charges,,,317.17,,,percent of total billed charges,,,310.25,,,percent of total billed charges,,,389.55,,,percent of total billed charges,,,,,,,,,401.07,,,percent of total billed charges,,,401.07,,,percent of total billed charges,,,391.85,,,percent of total billed charges,,,442.56,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,414.9,,,percent of total billed charges,,,,,,,,,428.73,,,percent of total billed charges,,,437.95,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,419.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR WO US GD LT,3262037,CDM,361,RC,20605,CPT,5441,APC,,,LT  ,outpatient,facility,,,461,461,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR MAJ WO US GD RT,3262045,CDM,361,RC,20610,CPT,,,,,RT  ,inpatient,facility,,,569,238.98,483.65,546.24,,483.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.03,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ WO US GD RT,3262045,CDM,361,RC,20610,CPT,,,,,RT  ,outpatient,facility,,,569,238.98,153.63,3428,,483.65,,,percent of total billed charges,,,153.63,,,percent of total billed charges,,,391.47,,,percent of total billed charges,,,382.94,,,percent of total billed charges,,,480.81,,,percent of total billed charges,,,,,,,,,495.03,,,percent of total billed charges,,,495.03,,,percent of total billed charges,,,483.65,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,517.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ WO US GD RT,3262045,CDM,361,RC,20610,CPT,5441,APC,,,RT  ,outpatient,facility,,,569,569,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR MAJ WO US GD BI,3262052,CDM,361,RC,20610,CPT,,,,,50,inpatient,facility,,,854,358.68,725.9,819.84,,725.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,742.98,,,percent of total billed charges,,,,,,,,,768.6,,,percent of total billed charges,,,819.84,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,794.22,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ WO US GD BI,3262052,CDM,361,RC,20610,CPT,,,,,50,outpatient,facility,,,854,358.68,230.58,3428,,725.9,,,percent of total billed charges,,,230.58,,,percent of total billed charges,,,587.55,,,percent of total billed charges,,,574.74,,,percent of total billed charges,,,721.63,,,percent of total billed charges,,,,,,,,,742.98,,,percent of total billed charges,,,742.98,,,percent of total billed charges,,,725.9,,,percent of total billed charges,,,819.84,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,768.6,,,percent of total billed charges,,,,,,,,,794.22,,,percent of total billed charges,,,811.3,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,777.14,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ WO US GD BI,3262052,CDM,361,RC,20610,CPT,5441,APC,,,50,outpatient,facility,,,854,854,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR MAJ WO US GD LT,3262060,CDM,361,RC,20610,CPT,,,,,LT  ,inpatient,facility,,,569,238.98,483.65,546.24,,483.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,495.03,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ WO US GD LT,3262060,CDM,361,RC,20610,CPT,,,,,LT  ,outpatient,facility,,,569,238.98,153.63,3428,,483.65,,,percent of total billed charges,,,153.63,,,percent of total billed charges,,,391.47,,,percent of total billed charges,,,382.94,,,percent of total billed charges,,,480.81,,,percent of total billed charges,,,,,,,,,495.03,,,percent of total billed charges,,,495.03,,,percent of total billed charges,,,483.65,,,percent of total billed charges,,,546.24,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,512.1,,,percent of total billed charges,,,,,,,,,529.17,,,percent of total billed charges,,,540.55,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,517.79,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ WO US GD LT,3262060,CDM,361,RC,20610,CPT,5441,APC,,,LT  ,outpatient,facility,,,569,569,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC STNT S ART CRV CAR W EMB S ANDI,3262086,CDM,361,RC,37215,CPT,,,,,,inpatient,facility,,,12873,5406.66,10942.05,12358.08,,10942.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11199.51,,,percent of total billed charges,,,,,,,,,11585.7,,,percent of total billed charges,,,12358.08,,,percent of total billed charges,,,12229.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11971.89,,,percent of total billed charges,,,12229.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S ART CRV CAR W EMB S ANDI,3262086,CDM,361,RC,37215,CPT,,,,,,outpatient,facility,,,12873,5406.66,3428,12873,,10942.05,,,percent of total billed charges,,,3475.71,,,percent of total billed charges,,,8856.62,,,percent of total billed charges,,,8663.53,,,percent of total billed charges,,,10877.68,,,percent of total billed charges,,,,,,,,,11199.51,,,percent of total billed charges,,,11199.51,,,percent of total billed charges,,,10942.05,,,percent of total billed charges,,,12358.08,,,percent of total billed charges,,,12229.35,,,percent of total billed charges,,,,,,,,,11585.7,,,percent of total billed charges,,,,,,,,,11971.89,,,percent of total billed charges,,,12229.35,,,percent of total billed charges,,,,,,,,,,,,,,,12873,,,fee schedule,,,12873,,,fee schedule,,,12873,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,11714.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC STNT S ART CRV CAR WO EMB S ANDI,3262094,CDM,361,RC,37216,CPT,,,,,,inpatient,facility,,,16015,6726.3,13612.75,15374.4,,13612.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13933.05,,,percent of total billed charges,,,,,,,,,14413.5,,,percent of total billed charges,,,15374.4,,,percent of total billed charges,,,15214.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,14893.95,,,percent of total billed charges,,,15214.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC STNT S ART CRV CAR WO EMB S ANDI,3262094,CDM,361,RC,37216,CPT,,,,,,outpatient,facility,,,16015,6726.3,3428,16015,,13612.75,,,percent of total billed charges,,,4324.05,,,percent of total billed charges,,,11018.32,,,percent of total billed charges,,,10778.09,,,percent of total billed charges,,,13532.67,,,percent of total billed charges,,,,,,,,,13933.05,,,percent of total billed charges,,,13933.05,,,percent of total billed charges,,,13612.75,,,percent of total billed charges,,,15374.4,,,percent of total billed charges,,,15214.25,,,percent of total billed charges,,,,,,,,,14413.5,,,percent of total billed charges,,,,,,,,,14893.95,,,percent of total billed charges,,,15214.25,,,percent of total billed charges,,,9609,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,16015,,,fee schedule,,,16015,,,fee schedule,,,16015,,,fee schedule,,,16015,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",3428,,,percent of total billed charges,,,14573.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VERTEBROPLASTY LUMBOSACRAL PERC,3262128,CDM,361,RC,22511,CPT,,,,,,inpatient,facility,,,6860,2881.2,5831,6585.6,,5831,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5968.2,,,percent of total billed charges,,,,,,,,,6174,,,percent of total billed charges,,,6585.6,,,percent of total billed charges,,,6517,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6379.8,,,percent of total billed charges,,,6517,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VERTEBROPLASTY LUMBOSACRAL PERC,3262128,CDM,361,RC,22511,CPT,,,,,,outpatient,facility,,,6860,2881.2,1852.2,15487,,5831,,,percent of total billed charges,,,1852.2,,,percent of total billed charges,,,4719.68,,,percent of total billed charges,,,4616.78,,,percent of total billed charges,,,5796.7,,,percent of total billed charges,,,,,,,,,5968.2,,,percent of total billed charges,,,5968.2,,,percent of total billed charges,,,5831,,,percent of total billed charges,,,6585.6,,,percent of total billed charges,,,6517,,,percent of total billed charges,,,,,,,,,6174,,,percent of total billed charges,,,,,,,,,6379.8,,,percent of total billed charges,,,6517,,,percent of total billed charges,,,,,,,,,,,,,,,3303,,,fee schedule,,,3303,,,fee schedule,,,3236.94,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6242.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VERTEBROPLASTY LUMBOSACRAL PERC,3262128,CDM,361,RC,22511,CPT,5113,APC,,,,outpatient,facility,,,6860,6860,1616.93,4789.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3303,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3369.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3303,,,fee schedule,,,,,,,,,,,,,,,4789.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4459.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3303,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3303,,,fee schedule,,,3303,,,fee schedule,,,1616.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VERTEBROPLASTY CRVTHOR LS PERC ADDL,3262136,CDM,361,RC,22512,CPT,,,,,,inpatient,facility,,,3503,1471.26,2977.55,3362.88,,2977.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3047.61,,,percent of total billed charges,,,,,,,,,3152.7,,,percent of total billed charges,,,3362.88,,,percent of total billed charges,,,3327.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3257.79,,,percent of total billed charges,,,3327.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VERTEBROPLASTY CRVTHOR LS PERC ADDL,3262136,CDM,361,RC,22512,CPT,,,,,,outpatient,facility,,,3503,1471.26,945.81,3503,,2977.55,,,percent of total billed charges,,,945.81,,,percent of total billed charges,,,2410.06,,,percent of total billed charges,,,2357.52,,,percent of total billed charges,,,2960.03,,,percent of total billed charges,,,,,,,,,3047.61,,,percent of total billed charges,,,3047.61,,,percent of total billed charges,,,2977.55,,,percent of total billed charges,,,3362.88,,,percent of total billed charges,,,3327.85,,,percent of total billed charges,,,,,,,,,3152.7,,,percent of total billed charges,,,,,,,,,3257.79,,,percent of total billed charges,,,3327.85,,,percent of total billed charges,,,,,,,,,,,,,,,3503,,,fee schedule,,,3503,,,fee schedule,,,3503,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,3187.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ LUMB MYELOGRPHY CERVICAL S ANDI,3263415,CDM,361,RC,62302,CPT,,,,,,inpatient,facility,,,2556,1073.52,2172.6,2453.76,,2172.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2223.72,,,percent of total billed charges,,,,,,,,,2300.4,,,percent of total billed charges,,,2453.76,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.08,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ LUMB MYELOGRPHY CERVICAL S ANDI,3263415,CDM,361,RC,62302,CPT,,,,,,outpatient,facility,,,2556,1073.52,690.12,3522,,2172.6,,,percent of total billed charges,,,690.12,,,percent of total billed charges,,,1758.53,,,percent of total billed charges,,,1720.19,,,percent of total billed charges,,,2159.82,,,percent of total billed charges,,,,,,,,,2223.72,,,percent of total billed charges,,,2223.72,,,percent of total billed charges,,,2172.6,,,percent of total billed charges,,,2453.76,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,2300.4,,,percent of total billed charges,,,,,,,,,2377.08,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,800.7,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2325.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ LUMB MYELOGRPHY CERVICAL S ANDI,3263415,CDM,361,RC,62302,CPT,5573,APC,,,,outpatient,facility,,,2556,2556,402.38,1184.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,1184.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1103,,,fee schedule,,,,,,,,,,,,,,,,,,,,,817.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,402.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ LUMB MYELOGRPHY THORACIC S ANDI,3263431,CDM,361,RC,62303,CPT,,,,,,inpatient,facility,,,2556,1073.52,2172.6,2453.76,,2172.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2223.72,,,percent of total billed charges,,,,,,,,,2300.4,,,percent of total billed charges,,,2453.76,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2377.08,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ LUMB MYELOGRPHY THORACIC S ANDI,3263431,CDM,361,RC,62303,CPT,,,,,,outpatient,facility,,,2556,1073.52,690.12,3522,,2172.6,,,percent of total billed charges,,,690.12,,,percent of total billed charges,,,1758.53,,,percent of total billed charges,,,1720.19,,,percent of total billed charges,,,2159.82,,,percent of total billed charges,,,,,,,,,2223.72,,,percent of total billed charges,,,2223.72,,,percent of total billed charges,,,2172.6,,,percent of total billed charges,,,2453.76,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,2300.4,,,percent of total billed charges,,,,,,,,,2377.08,,,percent of total billed charges,,,2428.2,,,percent of total billed charges,,,,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,800.7,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2325.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ LUMB MYELOGRPHY THORACIC S ANDI,3263431,CDM,361,RC,62303,CPT,5573,APC,,,,outpatient,facility,,,2556,2556,402.38,1184.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,1184.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1103,,,fee schedule,,,,,,,,,,,,,,,,,,,,,817.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,402.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ LUMB MYELOGRPHY LUMBOSACRAL S ANDI,3263456,CDM,361,RC,62304,CPT,,,,,,inpatient,facility,,,2690,1129.8,2286.5,2582.4,,2286.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2340.3,,,percent of total billed charges,,,,,,,,,2421,,,percent of total billed charges,,,2582.4,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.7,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ LUMB MYELOGRPHY LUMBOSACRAL S ANDI,3263456,CDM,361,RC,62304,CPT,,,,,,outpatient,facility,,,2690,1129.8,726.3,3522,,2286.5,,,percent of total billed charges,,,726.3,,,percent of total billed charges,,,1850.72,,,percent of total billed charges,,,1810.37,,,percent of total billed charges,,,2273.05,,,percent of total billed charges,,,,,,,,,2340.3,,,percent of total billed charges,,,2340.3,,,percent of total billed charges,,,2286.5,,,percent of total billed charges,,,2582.4,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,2421,,,percent of total billed charges,,,,,,,,,2501.7,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,800.7,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2447.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ LUMB MYELOGRPHY LUMBOSACRAL S ANDI,3263456,CDM,361,RC,62304,CPT,5573,APC,,,,outpatient,facility,,,2690,2690,402.38,1184.71,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,833.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,817.04,,,fee schedule,,,,,,,,,,,,,,,1184.71,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1103,,,fee schedule,,,,,,,,,,,,,,,,,,,,,817.04,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,817.04,,,fee schedule,,,817.04,,,fee schedule,,,402.38,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR INTR W US GD BI,3264389,CDM,361,RC,20606,CPT,,,,,50,inpatient,facility,,,990,415.8,841.5,950.4,,841.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,861.3,,,percent of total billed charges,,,,,,,,,891,,,percent of total billed charges,,,950.4,,,percent of total billed charges,,,940.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,920.7,,,percent of total billed charges,,,940.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR W US GD BI,3264389,CDM,361,RC,20606,CPT,,,,,50,outpatient,facility,,,990,415.8,267.3,3522,,841.5,,,percent of total billed charges,,,267.3,,,percent of total billed charges,,,681.12,,,percent of total billed charges,,,666.27,,,percent of total billed charges,,,836.55,,,percent of total billed charges,,,,,,,,,861.3,,,percent of total billed charges,,,861.3,,,percent of total billed charges,,,841.5,,,percent of total billed charges,,,950.4,,,percent of total billed charges,,,940.5,,,percent of total billed charges,,,,,,,,,891,,,percent of total billed charges,,,,,,,,,920.7,,,percent of total billed charges,,,940.5,,,percent of total billed charges,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,1037.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,900.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR W US GD BI,3264389,CDM,361,RC,20606,CPT,5442,APC,,,50,outpatient,facility,,,990,990,525.01,1534.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,1534.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1429,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1058.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,525.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR MAJ W US GD BI,3264587,CDM,361,RC,20611,CPT,,,,,50,inpatient,facility,,,1135,476.7,964.75,1089.6,,964.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,987.45,,,percent of total billed charges,,,,,,,,,1021.5,,,percent of total billed charges,,,1089.6,,,percent of total billed charges,,,1078.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1055.55,,,percent of total billed charges,,,1078.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ W US GD BI,3264587,CDM,361,RC,20611,CPT,,,,,50,outpatient,facility,,,1135,476.7,306.45,3428,,964.75,,,percent of total billed charges,,,306.45,,,percent of total billed charges,,,780.88,,,percent of total billed charges,,,763.85,,,percent of total billed charges,,,959.07,,,percent of total billed charges,,,,,,,,,987.45,,,percent of total billed charges,,,987.45,,,percent of total billed charges,,,964.75,,,percent of total billed charges,,,1089.6,,,percent of total billed charges,,,1078.25,,,percent of total billed charges,,,,,,,,,1021.5,,,percent of total billed charges,,,,,,,,,1055.55,,,percent of total billed charges,,,1078.25,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1032.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ W US GD BI,3264587,CDM,361,RC,20611,CPT,5441,APC,,,50,outpatient,facility,,,1135,1135,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR MAJ W US GD LT,3264595,CDM,361,RC,20611,CPT,,,,,LT  ,inpatient,facility,,,757,317.94,643.45,726.72,,643.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.59,,,percent of total billed charges,,,,,,,,,681.3,,,percent of total billed charges,,,726.72,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,704.01,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ W US GD LT,3264595,CDM,361,RC,20611,CPT,,,,,LT  ,outpatient,facility,,,757,317.94,204.39,3428,,643.45,,,percent of total billed charges,,,204.39,,,percent of total billed charges,,,520.82,,,percent of total billed charges,,,509.46,,,percent of total billed charges,,,639.66,,,percent of total billed charges,,,,,,,,,658.59,,,percent of total billed charges,,,658.59,,,percent of total billed charges,,,643.45,,,percent of total billed charges,,,726.72,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,681.3,,,percent of total billed charges,,,,,,,,,704.01,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,688.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ W US GD LT,3264595,CDM,361,RC,20611,CPT,5441,APC,,,LT  ,outpatient,facility,,,757,757,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR MAJ W US GD RT,3264603,CDM,361,RC,20611,CPT,,,,,RT  ,inpatient,facility,,,757,317.94,643.45,726.72,,643.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,658.59,,,percent of total billed charges,,,,,,,,,681.3,,,percent of total billed charges,,,726.72,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,704.01,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ W US GD RT,3264603,CDM,361,RC,20611,CPT,,,,,RT  ,outpatient,facility,,,757,317.94,204.39,3428,,643.45,,,percent of total billed charges,,,204.39,,,percent of total billed charges,,,520.82,,,percent of total billed charges,,,509.46,,,percent of total billed charges,,,639.66,,,percent of total billed charges,,,,,,,,,658.59,,,percent of total billed charges,,,658.59,,,percent of total billed charges,,,643.45,,,percent of total billed charges,,,726.72,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,681.3,,,percent of total billed charges,,,,,,,,,704.01,,,percent of total billed charges,,,719.15,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,688.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR MAJ W US GD RT,3264603,CDM,361,RC,20611,CPT,5441,APC,,,RT  ,outpatient,facility,,,757,757,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR INTR W US GD LT,3264652,CDM,361,RC,20606,CPT,,,,,LT  ,inpatient,facility,,,660,277.2,561,633.6,,561,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.2,,,percent of total billed charges,,,,,,,,,594,,,percent of total billed charges,,,633.6,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,613.8,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR W US GD LT,3264652,CDM,361,RC,20606,CPT,,,,,LT  ,outpatient,facility,,,660,277.2,178.2,3522,,561,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,454.08,,,percent of total billed charges,,,444.18,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,,,,,,,574.2,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,561,,,percent of total billed charges,,,633.6,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,594,,,percent of total billed charges,,,,,,,,,613.8,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR W US GD LT,3264652,CDM,361,RC,20606,CPT,5442,APC,,,LT  ,outpatient,facility,,,660,660,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR INTR W US GD RT,3264660,CDM,361,RC,20606,CPT,,,,,RT  ,inpatient,facility,,,660,277.2,561,633.6,,561,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,574.2,,,percent of total billed charges,,,,,,,,,594,,,percent of total billed charges,,,633.6,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,613.8,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR W US GD RT,3264660,CDM,361,RC,20606,CPT,,,,,RT  ,outpatient,facility,,,660,277.2,178.2,3522,,561,,,percent of total billed charges,,,178.2,,,percent of total billed charges,,,454.08,,,percent of total billed charges,,,444.18,,,percent of total billed charges,,,557.7,,,percent of total billed charges,,,,,,,,,574.2,,,percent of total billed charges,,,574.2,,,percent of total billed charges,,,561,,,percent of total billed charges,,,633.6,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,594,,,percent of total billed charges,,,,,,,,,613.8,,,percent of total billed charges,,,627,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,600.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR INTR W US GD RT,3264660,CDM,361,RC,20606,CPT,5442,APC,,,RT  ,outpatient,facility,,,660,660,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR SM W US GD BI,3264678,CDM,361,RC,20604,CPT,,,,,50,inpatient,facility,,,871,365.82,740.35,836.16,,740.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,757.77,,,percent of total billed charges,,,,,,,,,783.9,,,percent of total billed charges,,,836.16,,,percent of total billed charges,,,827.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,810.03,,,percent of total billed charges,,,827.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD BI,3264678,CDM,361,RC,20604,CPT,,,,,50,outpatient,facility,,,871,365.82,235.17,3428,,740.35,,,percent of total billed charges,,,235.17,,,percent of total billed charges,,,599.25,,,percent of total billed charges,,,586.18,,,percent of total billed charges,,,736,,,percent of total billed charges,,,,,,,,,757.77,,,percent of total billed charges,,,757.77,,,percent of total billed charges,,,740.35,,,percent of total billed charges,,,836.16,,,percent of total billed charges,,,827.45,,,percent of total billed charges,,,,,,,,,783.9,,,percent of total billed charges,,,,,,,,,810.03,,,percent of total billed charges,,,827.45,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,792.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD BI,3264678,CDM,361,RC,20604,CPT,5441,APC,,,50,outpatient,facility,,,871,871,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR SM W US GD LT,3264686,CDM,361,RC,20604,CPT,,,,,LT  ,inpatient,facility,,,581,244.02,493.85,557.76,,493.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.47,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD LT,3264686,CDM,361,RC,20604,CPT,,,,,LT  ,outpatient,facility,,,581,244.02,156.87,3428,,493.85,,,percent of total billed charges,,,156.87,,,percent of total billed charges,,,399.73,,,percent of total billed charges,,,391.01,,,percent of total billed charges,,,490.94,,,percent of total billed charges,,,,,,,,,505.47,,,percent of total billed charges,,,505.47,,,percent of total billed charges,,,493.85,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,528.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD LT,3264686,CDM,361,RC,20604,CPT,5441,APC,,,LT  ,outpatient,facility,,,581,581,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP AND INJ JT BUR SM W US GD RT,3264694,CDM,361,RC,20604,CPT,,,,,RT  ,inpatient,facility,,,581,244.02,493.85,557.76,,493.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.47,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD RT,3264694,CDM,361,RC,20604,CPT,,,,,RT  ,outpatient,facility,,,581,244.02,156.87,3428,,493.85,,,percent of total billed charges,,,156.87,,,percent of total billed charges,,,399.73,,,percent of total billed charges,,,391.01,,,percent of total billed charges,,,490.94,,,percent of total billed charges,,,,,,,,,505.47,,,percent of total billed charges,,,505.47,,,percent of total billed charges,,,493.85,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,528.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD RT,3264694,CDM,361,RC,20604,CPT,5441,APC,,,RT  ,outpatient,facility,,,581,581,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ SUBQ IM,3264751,CDM,940,RC,96372,CPT,,,,,,inpatient,facility,,,134,56.28,113.9,128.64,,113.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,116.58,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ SUBQ IM,3264751,CDM,940,RC,96372,CPT,,,,,,outpatient,facility,,,134,56.28,36.18,128.64,,113.9,,,percent of total billed charges,,,36.18,,,percent of total billed charges,,,92.19,,,percent of total billed charges,,,90.18,,,percent of total billed charges,,,113.23,,,percent of total billed charges,,,,,,,,,116.58,,,percent of total billed charges,,,116.58,,,percent of total billed charges,,,113.9,,,percent of total billed charges,,,128.64,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,120.6,,,percent of total billed charges,,,,,,,,,124.62,,,percent of total billed charges,,,127.3,,,percent of total billed charges,,,,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,70.45,,,fee schedule,,,,,,,,,104.65,,,percent of total billed charges,,,121.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ SUBQ IM,3264751,CDM,940,RC,96372,CPT,5692,APC,,,,outpatient,facility,,,134,134,36.65,104.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,104.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,71.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,36.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPR ENDOVAS AORTA THOR S ANDI,3265246,CDM,320,RC,75956,CPT,,,,,,inpatient,facility,,,847,355.74,719.95,813.12,,719.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,736.89,,,percent of total billed charges,,,,,,,,,762.3,,,percent of total billed charges,,,813.12,,,percent of total billed charges,,,804.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,787.71,,,percent of total billed charges,,,804.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPR ENDOVAS AORTA THOR S ANDI,3265246,CDM,320,RC,75956,CPT,,,,,,outpatient,facility,,,847,355.74,228.69,847,,719.95,,,percent of total billed charges,,,228.69,,,percent of total billed charges,,,582.74,,,percent of total billed charges,,,570.03,,,percent of total billed charges,,,715.72,,,percent of total billed charges,,,,,,,,,736.89,,,percent of total billed charges,,,736.89,,,percent of total billed charges,,,719.95,,,percent of total billed charges,,,813.12,,,percent of total billed charges,,,804.65,,,percent of total billed charges,,,,,,,,,762.3,,,percent of total billed charges,,,,,,,,,787.71,,,percent of total billed charges,,,804.65,,,percent of total billed charges,,,,,,,,,,,,,,,847,,,fee schedule,,,847,,,fee schedule,,,847,,,fee schedule,,,,,,,,,661.51,,,percent of total billed charges,,,770.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPR ENDOVAS AORTA THOR WO LSA S ANDI,3265253,CDM,320,RC,75957,CPT,,,,,,inpatient,facility,,,1519,637.98,1291.15,1458.24,,1291.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1321.53,,,percent of total billed charges,,,,,,,,,1367.1,,,percent of total billed charges,,,1458.24,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1412.67,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPR ENDOVAS AORTA THOR WO LSA S ANDI,3265253,CDM,320,RC,75957,CPT,,,,,,outpatient,facility,,,1519,637.98,410.13,1519,,1291.15,,,percent of total billed charges,,,410.13,,,percent of total billed charges,,,1045.07,,,percent of total billed charges,,,1022.29,,,percent of total billed charges,,,1283.56,,,percent of total billed charges,,,,,,,,,1321.53,,,percent of total billed charges,,,1321.53,,,percent of total billed charges,,,1291.15,,,percent of total billed charges,,,1458.24,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,1367.1,,,percent of total billed charges,,,,,,,,,1412.67,,,percent of total billed charges,,,1443.05,,,percent of total billed charges,,,,,,,,,,,,,,,1519,,,fee schedule,,,1519,,,fee schedule,,,1519,,,fee schedule,,,,,,,,,1186.34,,,percent of total billed charges,,,1382.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO SHOULDER BI,3265287,CDM,361,RC,23350,CPT,,,,,50,inpatient,facility,,,464,194.88,394.4,445.44,,394.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,403.68,,,percent of total billed charges,,,,,,,,,417.6,,,percent of total billed charges,,,445.44,,,percent of total billed charges,,,440.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,431.52,,,percent of total billed charges,,,440.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO SHOULDER BI,3265287,CDM,361,RC,23350,CPT,,,,,50,outpatient,facility,,,464,194.88,125.28,3428,,394.4,,,percent of total billed charges,,,125.28,,,percent of total billed charges,,,319.23,,,percent of total billed charges,,,312.27,,,percent of total billed charges,,,392.08,,,percent of total billed charges,,,,,,,,,403.68,,,percent of total billed charges,,,403.68,,,percent of total billed charges,,,394.4,,,percent of total billed charges,,,445.44,,,percent of total billed charges,,,440.8,,,percent of total billed charges,,,,,,,,,417.6,,,percent of total billed charges,,,,,,,,,431.52,,,percent of total billed charges,,,440.8,,,percent of total billed charges,,,,,,,,,,,,,,,464,,,fee schedule,,,464,,,fee schedule,,,464,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,422.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO SHOULDER LT,3265295,CDM,361,RC,23350,CPT,,,,,LT  ,inpatient,facility,,,309,129.78,262.65,296.64,,262.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.83,,,percent of total billed charges,,,,,,,,,278.1,,,percent of total billed charges,,,296.64,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.37,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO SHOULDER LT,3265295,CDM,361,RC,23350,CPT,,,,,LT  ,outpatient,facility,,,309,129.78,83.43,3428,,262.65,,,percent of total billed charges,,,83.43,,,percent of total billed charges,,,212.59,,,percent of total billed charges,,,207.96,,,percent of total billed charges,,,261.11,,,percent of total billed charges,,,,,,,,,268.83,,,percent of total billed charges,,,268.83,,,percent of total billed charges,,,262.65,,,percent of total billed charges,,,296.64,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,278.1,,,percent of total billed charges,,,,,,,,,287.37,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,,,,,,,309,,,fee schedule,,,309,,,fee schedule,,,309,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,281.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO SHOULDER RT,3265303,CDM,361,RC,23350,CPT,,,,,RT  ,inpatient,facility,,,309,129.78,262.65,296.64,,262.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,268.83,,,percent of total billed charges,,,,,,,,,278.1,,,percent of total billed charges,,,296.64,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,287.37,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ ARTHRO SHOULDER RT,3265303,CDM,361,RC,23350,CPT,,,,,RT  ,outpatient,facility,,,309,129.78,83.43,3428,,262.65,,,percent of total billed charges,,,83.43,,,percent of total billed charges,,,212.59,,,percent of total billed charges,,,207.96,,,percent of total billed charges,,,261.11,,,percent of total billed charges,,,,,,,,,268.83,,,percent of total billed charges,,,268.83,,,percent of total billed charges,,,262.65,,,percent of total billed charges,,,296.64,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,278.1,,,percent of total billed charges,,,,,,,,,287.37,,,percent of total billed charges,,,293.55,,,percent of total billed charges,,,,,,,,,,,,,,,309,,,fee schedule,,,309,,,fee schedule,,,309,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,281.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 VW RT RDC,3265337,CDM,320,RC,73060,CPT,,,,,52RT,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 VW RT RDC,3265337,CDM,320,RC,73060,CPT,,,,,52RT,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 VW RT RDC,3265337,CDM,320,RC,73060,CPT,5521,APC,,,52RT,outpatient,facility,,,111,111,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HUMERUS 2 VW LT RDC,3265345,CDM,320,RC,73060,CPT,,,,,52LT,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 VW LT RDC,3265345,CDM,320,RC,73060,CPT,,,,,52LT,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HUMERUS 2 VW LT RDC,3265345,CDM,320,RC,73060,CPT,5521,APC,,,52LT,outpatient,facility,,,111,111,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ELBOW 2 VW RT RDC,3265352,CDM,320,RC,73070,CPT,,,,,52RT,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW RT RDC,3265352,CDM,320,RC,73070,CPT,,,,,52RT,outpatient,facility,,,100,42,27,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,,,,,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW RT RDC,3265352,CDM,320,RC,73070,CPT,5521,APC,,,52RT,outpatient,facility,,,100,100,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ELBOW 2 VW LT RDC,3265360,CDM,320,RC,73070,CPT,,,,,52LT,inpatient,facility,,,100,42,85,96,,85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,87,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW LT RDC,3265360,CDM,320,RC,73070,CPT,,,,,52LT,outpatient,facility,,,100,42,27,96,,85,,,percent of total billed charges,,,27,,,percent of total billed charges,,,68.8,,,percent of total billed charges,,,67.3,,,percent of total billed charges,,,84.5,,,percent of total billed charges,,,,,,,,,87,,,percent of total billed charges,,,87,,,percent of total billed charges,,,85,,,percent of total billed charges,,,96,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,90,,,percent of total billed charges,,,,,,,,,93,,,percent of total billed charges,,,95,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,78.1,,,percent of total billed charges,,,91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ELBOW 2 VW LT RDC,3265360,CDM,320,RC,73070,CPT,5521,APC,,,52LT,outpatient,facility,,,100,100,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOREARM 2 VW RT RDC,3265386,CDM,320,RC,73090,CPT,,,,,52RT,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW RT RDC,3265386,CDM,320,RC,73090,CPT,,,,,52RT,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW RT RDC,3265386,CDM,320,RC,73090,CPT,5521,APC,,,52RT,outpatient,facility,,,111,111,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOREARM 2 VW LT RDC,3265394,CDM,320,RC,73090,CPT,,,,,52LT,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW LT RDC,3265394,CDM,320,RC,73090,CPT,,,,,52LT,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOREARM 2 VW LT RDC,3265394,CDM,320,RC,73090,CPT,5521,APC,,,52LT,outpatient,facility,,,111,111,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR WRIST 2 VW RT RDC,3265410,CDM,320,RC,73100,CPT,,,,,52RT,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW RT RDC,3265410,CDM,320,RC,73100,CPT,,,,,52RT,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW RT RDC,3265410,CDM,320,RC,73100,CPT,5521,APC,,,52RT,outpatient,facility,,,97,97,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR WRIST 2 VW LT RDC,3265428,CDM,320,RC,73100,CPT,,,,,52LT,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW LT RDC,3265428,CDM,320,RC,73100,CPT,,,,,52LT,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR WRIST 2 VW LT RDC,3265428,CDM,320,RC,73100,CPT,5521,APC,,,52LT,outpatient,facility,,,97,97,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HAND 2 VW RT RDC,3265444,CDM,320,RC,73120,CPT,,,,,52RT,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW RT RDC,3265444,CDM,320,RC,73120,CPT,,,,,52RT,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,fee schedule,,,56.1,,,fee schedule,,,54.98,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW RT RDC,3265444,CDM,320,RC,73120,CPT,5522,APC,,,52RT,outpatient,facility,,,97,97,29.03,81.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,56.09,,,fee schedule,,,,,,,,,,,,,,,81.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",75.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,56.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,56.09,,,fee schedule,,,56.09,,,fee schedule,,,29.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR HAND 2 VW LT RDC,3265451,CDM,320,RC,73120,CPT,,,,,52LT,inpatient,facility,,,97,40.74,82.45,93.12,,82.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,84.39,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW LT RDC,3265451,CDM,320,RC,73120,CPT,,,,,52LT,outpatient,facility,,,97,40.74,26.19,93.12,,82.45,,,percent of total billed charges,,,26.19,,,percent of total billed charges,,,66.74,,,percent of total billed charges,,,65.28,,,percent of total billed charges,,,81.97,,,percent of total billed charges,,,,,,,,,84.39,,,percent of total billed charges,,,84.39,,,percent of total billed charges,,,82.45,,,percent of total billed charges,,,93.12,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,87.3,,,percent of total billed charges,,,,,,,,,90.21,,,percent of total billed charges,,,92.15,,,percent of total billed charges,,,,,,,,,,,,,,,56.1,,,fee schedule,,,56.1,,,fee schedule,,,54.98,,,fee schedule,,,,,,,,,75.76,,,percent of total billed charges,,,88.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR HAND 2 VW LT RDC,3265451,CDM,320,RC,73120,CPT,5522,APC,,,52LT,outpatient,facility,,,97,97,29.03,81.33,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,56.09,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,57.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,56.09,,,fee schedule,,,,,,,,,,,,,,,81.33,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",75.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,56.09,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,56.09,,,fee schedule,,,56.09,,,fee schedule,,,29.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TIBIA ANDFIBULA 2 VW RT RDC,3265477,CDM,320,RC,73590,CPT,,,,,52RT,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW RT RDC,3265477,CDM,320,RC,73590,CPT,,,,,52RT,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW RT RDC,3265477,CDM,320,RC,73590,CPT,5521,APC,,,52RT,outpatient,facility,,,111,111,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR TIBIA ANDFIBULA 2 VW LT RDC,3265485,CDM,320,RC,73590,CPT,,,,,52LT,inpatient,facility,,,111,46.62,94.35,106.56,,94.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,96.57,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW LT RDC,3265485,CDM,320,RC,73590,CPT,,,,,52LT,outpatient,facility,,,111,46.62,29.97,106.56,,94.35,,,percent of total billed charges,,,29.97,,,percent of total billed charges,,,76.37,,,percent of total billed charges,,,74.7,,,percent of total billed charges,,,93.8,,,percent of total billed charges,,,,,,,,,96.57,,,percent of total billed charges,,,96.57,,,percent of total billed charges,,,94.35,,,percent of total billed charges,,,106.56,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,99.9,,,percent of total billed charges,,,,,,,,,103.23,,,percent of total billed charges,,,105.45,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,86.69,,,percent of total billed charges,,,101.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR TIBIA ANDFIBULA 2 VW LT RDC,3265485,CDM,320,RC,73590,CPT,5521,APC,,,52LT,outpatient,facility,,,111,111,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ANKLE 2 VW RT RDC,3265501,CDM,320,RC,73600,CPT,,,,,52RT,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW RT RDC,3265501,CDM,320,RC,73600,CPT,,,,,52RT,outpatient,facility,,,103,43.26,27.81,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,,,,,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW RT RDC,3265501,CDM,320,RC,73600,CPT,5521,APC,,,52RT,outpatient,facility,,,103,103,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ANKLE 2 VW LT RDC,3265519,CDM,320,RC,73600,CPT,,,,,52LT,inpatient,facility,,,103,43.26,87.55,98.88,,87.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,89.61,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW LT RDC,3265519,CDM,320,RC,73600,CPT,,,,,52LT,outpatient,facility,,,103,43.26,27.81,98.88,,87.55,,,percent of total billed charges,,,27.81,,,percent of total billed charges,,,70.86,,,percent of total billed charges,,,69.32,,,percent of total billed charges,,,87.03,,,percent of total billed charges,,,,,,,,,89.61,,,percent of total billed charges,,,89.61,,,percent of total billed charges,,,87.55,,,percent of total billed charges,,,98.88,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,92.7,,,percent of total billed charges,,,,,,,,,95.79,,,percent of total billed charges,,,97.85,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,80.44,,,percent of total billed charges,,,93.73,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ANKLE 2 VW LT RDC,3265519,CDM,320,RC,73600,CPT,5521,APC,,,52LT,outpatient,facility,,,103,103,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOOT 2 VW RT RDC,3265535,CDM,320,RC,73620,CPT,,,,,52RT,inpatient,facility,,,96,40.32,81.6,92.16,,81.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.52,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW RT RDC,3265535,CDM,320,RC,73620,CPT,,,,,52RT,outpatient,facility,,,96,40.32,25.92,92.16,,81.6,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,81.12,,,percent of total billed charges,,,,,,,,,83.52,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,74.98,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW RT RDC,3265535,CDM,320,RC,73620,CPT,5521,APC,,,52RT,outpatient,facility,,,96,96,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR FOOT 2 VW LT RDC,3265543,CDM,320,RC,73620,CPT,,,,,52LT,inpatient,facility,,,96,40.32,81.6,92.16,,81.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,83.52,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW LT RDC,3265543,CDM,320,RC,73620,CPT,,,,,52LT,outpatient,facility,,,96,40.32,25.92,92.16,,81.6,,,percent of total billed charges,,,25.92,,,percent of total billed charges,,,66.05,,,percent of total billed charges,,,64.61,,,percent of total billed charges,,,81.12,,,percent of total billed charges,,,,,,,,,83.52,,,percent of total billed charges,,,83.52,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,92.16,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,86.4,,,percent of total billed charges,,,,,,,,,89.28,,,percent of total billed charges,,,91.2,,,percent of total billed charges,,,,,,,,,,,,,,,46.37,,,fee schedule,,,46.37,,,fee schedule,,,45.44,,,fee schedule,,,,,,,,,74.98,,,percent of total billed charges,,,87.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR FOOT 2 VW LT RDC,3265543,CDM,320,RC,73620,CPT,5521,APC,,,52LT,outpatient,facility,,,96,96,23.6,67.22,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,47.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,46.36,,,fee schedule,,,,,,,,,,,,,,,67.22,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",62.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,46.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,46.36,,,fee schedule,,,46.36,,,fee schedule,,,23.6,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP NEEDLE FINE BX US GD LSN 1ST,3265600,CDM,361,RC,10005,CPT,,,,,,inpatient,facility,,,1784,749.28,1516.4,1712.64,,1516.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1552.08,,,percent of total billed charges,,,,,,,,,1605.6,,,percent of total billed charges,,,1712.64,,,percent of total billed charges,,,1694.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1659.12,,,percent of total billed charges,,,1694.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP NEEDLE FINE BX US GD LSN 1ST,3265600,CDM,361,RC,10005,CPT,,,,,,outpatient,facility,,,1784,749.28,481.68,3522,,1516.4,,,percent of total billed charges,,,481.68,,,percent of total billed charges,,,1227.39,,,percent of total billed charges,,,1200.63,,,percent of total billed charges,,,1507.48,,,percent of total billed charges,,,,,,,,,1552.08,,,percent of total billed charges,,,1552.08,,,percent of total billed charges,,,1516.4,,,percent of total billed charges,,,1712.64,,,percent of total billed charges,,,1694.8,,,percent of total billed charges,,,,,,,,,1605.6,,,percent of total billed charges,,,,,,,,,1659.12,,,percent of total billed charges,,,1694.8,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1623.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP NEEDLE FINE BX US GD LSN 1ST,3265600,CDM,361,RC,10005,CPT,5071,APC,,,,outpatient,facility,,,1784,1784,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ASP NEEDLE FINE BX US GD LSN ADDL,3265618,CDM,361,RC,10006,CPT,,,,,,inpatient,facility,,,1213,509.46,1031.05,1164.48,,1031.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1055.31,,,percent of total billed charges,,,,,,,,,1091.7,,,percent of total billed charges,,,1164.48,,,percent of total billed charges,,,1152.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1128.09,,,percent of total billed charges,,,1152.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP NEEDLE FINE BX US GD LSN ADDL,3265618,CDM,361,RC,10006,CPT,,,,,,outpatient,facility,,,1213,509.46,327.51,3428,,1031.05,,,percent of total billed charges,,,327.51,,,percent of total billed charges,,,834.54,,,percent of total billed charges,,,816.35,,,percent of total billed charges,,,1024.98,,,percent of total billed charges,,,,,,,,,1055.31,,,percent of total billed charges,,,1055.31,,,percent of total billed charges,,,1031.05,,,percent of total billed charges,,,1164.48,,,percent of total billed charges,,,1152.35,,,percent of total billed charges,,,,,,,,,1091.7,,,percent of total billed charges,,,,,,,,,1128.09,,,percent of total billed charges,,,1152.35,,,percent of total billed charges,,,,,,,,,,,,,,,1213,,,fee schedule,,,1213,,,fee schedule,,,1213,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1103.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP NEEDLE FINE BX FL GD LSN 1ST,3265626,CDM,361,RC,10007,CPT,,,,,,inpatient,facility,,,2301,966.42,1955.85,2208.96,,1955.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2001.87,,,percent of total billed charges,,,,,,,,,2070.9,,,percent of total billed charges,,,2208.96,,,percent of total billed charges,,,2185.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2139.93,,,percent of total billed charges,,,2185.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP NEEDLE FINE BX FL GD LSN 1ST,3265626,CDM,361,RC,10007,CPT,,,,,,outpatient,facility,,,2301,966.42,621.27,3522,,1955.85,,,percent of total billed charges,,,621.27,,,percent of total billed charges,,,1583.09,,,percent of total billed charges,,,1548.57,,,percent of total billed charges,,,1944.35,,,percent of total billed charges,,,,,,,,,2001.87,,,percent of total billed charges,,,2001.87,,,percent of total billed charges,,,1955.85,,,percent of total billed charges,,,2208.96,,,percent of total billed charges,,,2185.95,,,percent of total billed charges,,,,,,,,,2070.9,,,percent of total billed charges,,,,,,,,,2139.93,,,percent of total billed charges,,,2185.95,,,percent of total billed charges,,,,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,703.6,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2093.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP NEEDLE FINE BX FL GD LSN 1ST,3265626,CDM,361,RC,10007,CPT,5071,APC,,,,outpatient,facility,,,2301,2301,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS PICC WO P P W IMG 0 4YRS,3265667,CDM,361,RC,36572,CPT,,,,,,inpatient,facility,,,2506,1052.52,2130.1,2405.76,,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2180.22,,,percent of total billed charges,,,,,,,,,2255.4,,,percent of total billed charges,,,2405.76,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2330.58,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P W IMG 0 4YRS,3265667,CDM,361,RC,36572,CPT,,,,,,outpatient,facility,,,2506,1052.52,628.23,3522,,2130.1,,,percent of total billed charges,,,676.62,,,percent of total billed charges,,,1724.13,,,percent of total billed charges,,,1686.54,,,percent of total billed charges,,,2117.57,,,percent of total billed charges,,,,,,,,,2180.22,,,percent of total billed charges,,,2180.22,,,percent of total billed charges,,,2130.1,,,percent of total billed charges,,,2405.76,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,2255.4,,,percent of total billed charges,,,,,,,,,2330.58,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2280.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P W IMG 0 4YRS,3265667,CDM,361,RC,36572,CPT,5181,APC,,,,outpatient,facility,,,2506,2506,314.24,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,314.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS PICC WO P P W IMG 5 PLUSYRS,3265675,CDM,361,RC,36573,CPT,,,,,,inpatient,facility,,,2325,976.5,1976.25,2232,,1976.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2022.75,,,percent of total billed charges,,,,,,,,,2092.5,,,percent of total billed charges,,,2232,,,percent of total billed charges,,,2208.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2162.25,,,percent of total billed charges,,,2208.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P W IMG 5 PLUSYRS,3265675,CDM,361,RC,36573,CPT,,,,,,outpatient,facility,,,2325,976.5,627.75,5933,,1976.25,,,percent of total billed charges,,,627.75,,,percent of total billed charges,,,1599.6,,,percent of total billed charges,,,1564.72,,,percent of total billed charges,,,1964.63,,,percent of total billed charges,,,,,,,,,2022.75,,,percent of total billed charges,,,2022.75,,,percent of total billed charges,,,1976.25,,,percent of total billed charges,,,2232,,,percent of total billed charges,,,2208.75,,,percent of total billed charges,,,,,,,,,2092.5,,,percent of total billed charges,,,,,,,,,2162.25,,,percent of total billed charges,,,2208.75,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,2115.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P W IMG 5 PLUSYRS,3265675,CDM,361,RC,36573,CPT,5182,APC,,,,outpatient,facility,,,2325,2325,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL TRACT EXIST PERC BI S ANDI,3265683,CDM,361,RC,50436,CPT,,,,,50,inpatient,facility,,,4333,1819.86,3683.05,4159.68,,3683.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3769.71,,,percent of total billed charges,,,,,,,,,3899.7,,,percent of total billed charges,,,4159.68,,,percent of total billed charges,,,4116.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4029.69,,,percent of total billed charges,,,4116.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC BI S ANDI,3265683,CDM,361,RC,50436,CPT,,,,,50,outpatient,facility,,,4333,1819.86,1169.91,11510,,3683.05,,,percent of total billed charges,,,1169.91,,,percent of total billed charges,,,2981.1,,,percent of total billed charges,,,2916.11,,,percent of total billed charges,,,3661.38,,,percent of total billed charges,,,,,,,,,3769.71,,,percent of total billed charges,,,3769.71,,,percent of total billed charges,,,3683.05,,,percent of total billed charges,,,4159.68,,,percent of total billed charges,,,4116.35,,,percent of total billed charges,,,,,,,,,3899.7,,,percent of total billed charges,,,,,,,,,4029.69,,,percent of total billed charges,,,4116.35,,,percent of total billed charges,,,,,,,,,,,,,,,4333,,,fee schedule,,,4333,,,fee schedule,,,4333,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3943.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC BI S ANDI,3265683,CDM,361,RC,50436,CPT,5374,APC,,,50,outpatient,facility,,,4333,4333,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL TRACT EXIST PERC LT S ANDI,3265691,CDM,361,RC,50436,CPT,,,,,LT  ,inpatient,facility,,,2889,1213.38,2455.65,2773.44,,2455.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2513.43,,,percent of total billed charges,,,,,,,,,2600.1,,,percent of total billed charges,,,2773.44,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2686.77,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC LT S ANDI,3265691,CDM,361,RC,50436,CPT,,,,,LT  ,outpatient,facility,,,2889,1213.38,780.03,11510,,2455.65,,,percent of total billed charges,,,780.03,,,percent of total billed charges,,,1987.63,,,percent of total billed charges,,,1944.3,,,percent of total billed charges,,,2441.2,,,percent of total billed charges,,,,,,,,,2513.43,,,percent of total billed charges,,,2513.43,,,percent of total billed charges,,,2455.65,,,percent of total billed charges,,,2773.44,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,2600.1,,,percent of total billed charges,,,,,,,,,2686.77,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,,,,,,,2889,,,fee schedule,,,2889,,,fee schedule,,,2889,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2628.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC LT S ANDI,3265691,CDM,361,RC,50436,CPT,5374,APC,,,LT  ,outpatient,facility,,,2889,2889,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL TRACT EXIST PERC RT S ANDI,3265709,CDM,361,RC,50436,CPT,,,,,RT  ,inpatient,facility,,,2889,1213.38,2455.65,2773.44,,2455.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2513.43,,,percent of total billed charges,,,,,,,,,2600.1,,,percent of total billed charges,,,2773.44,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2686.77,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC RT S ANDI,3265709,CDM,361,RC,50436,CPT,,,,,RT  ,outpatient,facility,,,2889,1213.38,780.03,11510,,2455.65,,,percent of total billed charges,,,780.03,,,percent of total billed charges,,,1987.63,,,percent of total billed charges,,,1944.3,,,percent of total billed charges,,,2441.2,,,percent of total billed charges,,,,,,,,,2513.43,,,percent of total billed charges,,,2513.43,,,percent of total billed charges,,,2455.65,,,percent of total billed charges,,,2773.44,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,2600.1,,,percent of total billed charges,,,,,,,,,2686.77,,,percent of total billed charges,,,2744.55,,,percent of total billed charges,,,,,,,,,,,,,,,2889,,,fee schedule,,,2889,,,fee schedule,,,2889,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2628.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC RT S ANDI,3265709,CDM,361,RC,50436,CPT,5374,APC,,,RT  ,outpatient,facility,,,2889,2889,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL TRACT EXIST PERC NEW ACC BI S ANDI,3265717,CDM,361,RC,50437,CPT,,,,,50,inpatient,facility,,,7280,3057.6,6188,6988.8,,6188,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6333.6,,,percent of total billed charges,,,,,,,,,6552,,,percent of total billed charges,,,6988.8,,,percent of total billed charges,,,6916,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6770.4,,,percent of total billed charges,,,6916,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC NEW ACC BI S ANDI,3265717,CDM,361,RC,50437,CPT,,,,,50,outpatient,facility,,,7280,3057.6,1965.6,15487,,6188,,,percent of total billed charges,,,1965.6,,,percent of total billed charges,,,5008.64,,,percent of total billed charges,,,4899.44,,,percent of total billed charges,,,6151.6,,,percent of total billed charges,,,,,,,,,6333.6,,,percent of total billed charges,,,6333.6,,,percent of total billed charges,,,6188,,,percent of total billed charges,,,6988.8,,,percent of total billed charges,,,6916,,,percent of total billed charges,,,,,,,,,6552,,,percent of total billed charges,,,,,,,,,6770.4,,,percent of total billed charges,,,6916,,,percent of total billed charges,,,,,,,,,,,,,,,7280,,,fee schedule,,,7280,,,fee schedule,,,7280,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6624.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC NEW ACC BI S ANDI,3265717,CDM,361,RC,50437,CPT,5374,APC,,,50,outpatient,facility,,,7280,7280,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL TRACT EXIST PERC NEW ACC LT S ANDI,3265725,CDM,361,RC,50437,CPT,,,,,LT  ,inpatient,facility,,,4853,2038.26,4125.05,4658.88,,4125.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4222.11,,,percent of total billed charges,,,,,,,,,4367.7,,,percent of total billed charges,,,4658.88,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4513.29,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC NEW ACC LT S ANDI,3265725,CDM,361,RC,50437,CPT,,,,,LT  ,outpatient,facility,,,4853,2038.26,1310.31,15487,,4125.05,,,percent of total billed charges,,,1310.31,,,percent of total billed charges,,,3338.86,,,percent of total billed charges,,,3266.07,,,percent of total billed charges,,,4100.78,,,percent of total billed charges,,,,,,,,,4222.11,,,percent of total billed charges,,,4222.11,,,percent of total billed charges,,,4125.05,,,percent of total billed charges,,,4658.88,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,4367.7,,,percent of total billed charges,,,,,,,,,4513.29,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,,,,,,,4853,,,fee schedule,,,4853,,,fee schedule,,,4853,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4416.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC NEW ACC LT S ANDI,3265725,CDM,361,RC,50437,CPT,5374,APC,,,LT  ,outpatient,facility,,,4853,4853,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DIL TRACT EXIST PERC NEW ACC RT S ANDI,3265733,CDM,361,RC,50437,CPT,,,,,RT  ,inpatient,facility,,,4853,2038.26,4125.05,4658.88,,4125.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4222.11,,,percent of total billed charges,,,,,,,,,4367.7,,,percent of total billed charges,,,4658.88,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4513.29,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC NEW ACC RT S ANDI,3265733,CDM,361,RC,50437,CPT,,,,,RT  ,outpatient,facility,,,4853,2038.26,1310.31,15487,,4125.05,,,percent of total billed charges,,,1310.31,,,percent of total billed charges,,,3338.86,,,percent of total billed charges,,,3266.07,,,percent of total billed charges,,,4100.78,,,percent of total billed charges,,,,,,,,,4222.11,,,percent of total billed charges,,,4222.11,,,percent of total billed charges,,,4125.05,,,percent of total billed charges,,,4658.88,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,4367.7,,,percent of total billed charges,,,,,,,,,4513.29,,,percent of total billed charges,,,4610.35,,,percent of total billed charges,,,,,,,,,,,,,,,4853,,,fee schedule,,,4853,,,fee schedule,,,4853,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,4416.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DIL TRACT EXIST PERC NEW ACC RT S ANDI,3265733,CDM,361,RC,50437,CPT,5374,APC,,,RT  ,outpatient,facility,,,4853,4853,1741.03,5158.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3628.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3557.41,,,fee schedule,,,,,,,,,,,,,,,5158.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4802.5,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3557.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3557.41,,,fee schedule,,,3557.41,,,fee schedule,,,1741.03,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS PICC WO P P WO IMG 0 4YRS,3265741,CDM,361,RC,36568,CPT,,,,,,inpatient,facility,,,2506,1052.52,2130.1,2405.76,,2130.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2180.22,,,percent of total billed charges,,,,,,,,,2255.4,,,percent of total billed charges,,,2405.76,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2330.58,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P WO IMG 0 4YRS,3265741,CDM,361,RC,36568,CPT,,,,,,outpatient,facility,,,2506,1052.52,676.62,3522,,2130.1,,,percent of total billed charges,,,676.62,,,percent of total billed charges,,,1724.13,,,percent of total billed charges,,,1686.54,,,percent of total billed charges,,,2117.57,,,percent of total billed charges,,,,,,,,,2180.22,,,percent of total billed charges,,,2180.22,,,percent of total billed charges,,,2130.1,,,percent of total billed charges,,,2405.76,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,2255.4,,,percent of total billed charges,,,,,,,,,2330.58,,,percent of total billed charges,,,2380.7,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2280.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P WO IMG 0 4YRS,3265741,CDM,361,RC,36568,CPT,5182,APC,,,,outpatient,facility,,,2506,2506,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INS PICC WO P P WO IMG 5 PLUSYRS,3265758,CDM,361,RC,36569,CPT,,,,,,inpatient,facility,,,2584,1085.28,2196.4,2480.64,,2196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2248.08,,,percent of total billed charges,,,,,,,,,2325.6,,,percent of total billed charges,,,2480.64,,,percent of total billed charges,,,2454.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2403.12,,,percent of total billed charges,,,2454.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P WO IMG 5 PLUSYRS,3265758,CDM,361,RC,36569,CPT,,,,,,outpatient,facility,,,2584,1085.28,697.68,3522,,2196.4,,,percent of total billed charges,,,697.68,,,percent of total billed charges,,,1777.79,,,percent of total billed charges,,,1739.03,,,percent of total billed charges,,,2183.48,,,percent of total billed charges,,,,,,,,,2248.08,,,percent of total billed charges,,,2248.08,,,percent of total billed charges,,,2196.4,,,percent of total billed charges,,,2480.64,,,percent of total billed charges,,,2454.8,,,percent of total billed charges,,,,,,,,,2325.6,,,percent of total billed charges,,,,,,,,,2403.12,,,percent of total billed charges,,,2454.8,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2351.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS PICC WO P P WO IMG 5 PLUSYRS,3265758,CDM,361,RC,36569,CPT,5182,APC,,,,outpatient,facility,,,2584,2584,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RPLC PICC WO P P SA S ANDI,3265766,CDM,361,RC,36584,CPT,,,,,,inpatient,facility,,,3004,1261.68,2553.4,2883.84,,2553.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2613.48,,,percent of total billed charges,,,,,,,,,2703.6,,,percent of total billed charges,,,2883.84,,,percent of total billed charges,,,2853.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2793.72,,,percent of total billed charges,,,2853.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RPLC PICC WO P P SA S ANDI,3265766,CDM,361,RC,36584,CPT,,,,,,outpatient,facility,,,3004,1261.68,811.08,3522,,2553.4,,,percent of total billed charges,,,811.08,,,percent of total billed charges,,,2066.75,,,percent of total billed charges,,,2021.69,,,percent of total billed charges,,,2538.38,,,percent of total billed charges,,,,,,,,,2613.48,,,percent of total billed charges,,,2613.48,,,percent of total billed charges,,,2553.4,,,percent of total billed charges,,,2883.84,,,percent of total billed charges,,,2853.8,,,percent of total billed charges,,,,,,,,,2703.6,,,percent of total billed charges,,,,,,,,,2793.72,,,percent of total billed charges,,,2853.8,,,percent of total billed charges,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,1601.58,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2733.64,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RPLC PICC WO P P SA S ANDI,3265766,CDM,361,RC,36584,CPT,5182,APC,,,,outpatient,facility,,,3004,3004,808.21,2369.69,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1666.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1634.27,,,fee schedule,,,,,,,,,,,,,,,2369.69,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2206.26,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1634.27,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1634.27,,,fee schedule,,,1634.27,,,fee schedule,,,808.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC DEV S LOC TIS SOFT PERC LSN 1ST,3265790,CDM,361,RC,10035,CPT,,,,,,inpatient,facility,,,1655,695.1,1406.75,1588.8,,1406.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1439.85,,,percent of total billed charges,,,,,,,,,1489.5,,,percent of total billed charges,,,1588.8,,,percent of total billed charges,,,1572.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1539.15,,,percent of total billed charges,,,1572.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC DEV S LOC TIS SOFT PERC LSN 1ST,3265790,CDM,361,RC,10035,CPT,,,,,,outpatient,facility,,,1655,695.1,446.85,3522,,1406.75,,,percent of total billed charges,,,446.85,,,percent of total billed charges,,,1138.64,,,percent of total billed charges,,,1113.81,,,percent of total billed charges,,,1398.47,,,percent of total billed charges,,,,,,,,,1439.85,,,percent of total billed charges,,,1439.85,,,percent of total billed charges,,,1406.75,,,percent of total billed charges,,,1588.8,,,percent of total billed charges,,,1572.25,,,percent of total billed charges,,,,,,,,,1489.5,,,percent of total billed charges,,,,,,,,,1539.15,,,percent of total billed charges,,,1572.25,,,percent of total billed charges,,,,,,,,,,,,,,,1655,,,fee schedule,,,1655,,,fee schedule,,,1655,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1506.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLC DEV S LOC TIS SOFT PERC LSN 1ST,3265790,CDM,361,RC,10035,CPT,5071,APC,,,,outpatient,facility,,,1655,1655,352.52,1041.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,732.32,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,717.96,,,fee schedule,,,,,,,,,,,,,,,1041.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",969.25,,,fee schedule,,,,,,,,,,,,,,,,,,,,,717.96,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,717.96,,,fee schedule,,,717.96,,,fee schedule,,,352.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLC DEV S LOC TIS SOFT PERC LSN ADD,3265808,CDM,361,RC,10036,CPT,,,,,,inpatient,facility,,,828,347.76,703.8,794.88,,703.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,720.36,,,percent of total billed charges,,,,,,,,,745.2,,,percent of total billed charges,,,794.88,,,percent of total billed charges,,,786.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,770.04,,,percent of total billed charges,,,786.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLC DEV S LOC TIS SOFT PERC LSN ADD,3265808,CDM,361,RC,10036,CPT,,,,,,outpatient,facility,,,828,347.76,223.56,3428,,703.8,,,percent of total billed charges,,,223.56,,,percent of total billed charges,,,569.66,,,percent of total billed charges,,,557.24,,,percent of total billed charges,,,699.66,,,percent of total billed charges,,,,,,,,,720.36,,,percent of total billed charges,,,720.36,,,percent of total billed charges,,,703.8,,,percent of total billed charges,,,794.88,,,percent of total billed charges,,,786.6,,,percent of total billed charges,,,,,,,,,745.2,,,percent of total billed charges,,,,,,,,,770.04,,,percent of total billed charges,,,786.6,,,percent of total billed charges,,,,,,,,,,,,,,,828,,,fee schedule,,,828,,,fee schedule,,,828,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,753.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ESOPHAGUS STUDY CNT SINGLE,3266020,CDM,320,RC,74220,CPT,,,,,,inpatient,facility,,,256,107.52,217.6,245.76,,217.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ESOPHAGUS STUDY CNT SINGLE,3266020,CDM,320,RC,74220,CPT,,,,,,outpatient,facility,,,256,107.52,69.12,245.76,,217.6,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,176.13,,,percent of total billed charges,,,172.29,,,percent of total billed charges,,,216.32,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,217.6,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,199.94,,,percent of total billed charges,,,232.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ESOPHAGUS STUDY CNT SINGLE,3266020,CDM,320,RC,74220,CPT,5571,APC,,,,outpatient,facility,,,256,256,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
FNCT SWALLOW W CINE VIDEO STUDY CNT,3266038,CDM,320,RC,74230,CPT,,,,,,inpatient,facility,,,256,107.52,217.6,245.76,,217.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
FNCT SWALLOW W CINE VIDEO STUDY CNT,3266038,CDM,320,RC,74230,CPT,,,,,,outpatient,facility,,,256,107.52,69.12,245.76,,217.6,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,176.13,,,percent of total billed charges,,,172.29,,,percent of total billed charges,,,216.32,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,217.6,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,199.94,,,percent of total billed charges,,,232.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
FNCT SWALLOW W CINE VIDEO STUDY CNT,3266038,CDM,320,RC,74230,CPT,5571,APC,,,,outpatient,facility,,,256,256,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR UGI STUDY CNT SINGLE,3266046,CDM,320,RC,74240,CPT,,,,,,inpatient,facility,,,323,135.66,274.55,310.08,,274.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.01,,,percent of total billed charges,,,,,,,,,290.7,,,percent of total billed charges,,,310.08,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,300.39,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR UGI STUDY CNT SINGLE,3266046,CDM,320,RC,74240,CPT,,,,,,outpatient,facility,,,323,135.66,87.21,310.08,,274.55,,,percent of total billed charges,,,87.21,,,percent of total billed charges,,,222.22,,,percent of total billed charges,,,217.38,,,percent of total billed charges,,,272.94,,,percent of total billed charges,,,,,,,,,281.01,,,percent of total billed charges,,,281.01,,,percent of total billed charges,,,274.55,,,percent of total billed charges,,,310.08,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,290.7,,,percent of total billed charges,,,,,,,,,300.39,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,252.26,,,percent of total billed charges,,,293.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR UGI STUDY CNT SINGLE,3266046,CDM,320,RC,74240,CPT,5571,APC,,,,outpatient,facility,,,323,323,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR UGI STUDY CNT DOUBLE,3266053,CDM,320,RC,74246,CPT,,,,,,inpatient,facility,,,323,135.66,274.55,310.08,,274.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,281.01,,,percent of total billed charges,,,,,,,,,290.7,,,percent of total billed charges,,,310.08,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,300.39,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR UGI STUDY CNT DOUBLE,3266053,CDM,320,RC,74246,CPT,,,,,,outpatient,facility,,,323,135.66,87.21,310.08,,274.55,,,percent of total billed charges,,,87.21,,,percent of total billed charges,,,222.22,,,percent of total billed charges,,,217.38,,,percent of total billed charges,,,272.94,,,percent of total billed charges,,,,,,,,,281.01,,,percent of total billed charges,,,281.01,,,percent of total billed charges,,,274.55,,,percent of total billed charges,,,310.08,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,290.7,,,percent of total billed charges,,,,,,,,,300.39,,,percent of total billed charges,,,306.85,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,252.26,,,percent of total billed charges,,,293.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR UGI STUDY CNT DOUBLE,3266053,CDM,320,RC,74246,CPT,5571,APC,,,,outpatient,facility,,,323,323,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR INTESTINE SM STUDY FOLLOW THRU,3266061,CDM,320,RC,74248,CPT,,,,,,inpatient,facility,,,128,53.76,108.8,122.88,,108.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,111.36,,,percent of total billed charges,,,,,,,,,115.2,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR INTESTINE SM STUDY FOLLOW THRU,3266061,CDM,320,RC,74248,CPT,,,,,,outpatient,facility,,,128,53.76,34.56,128,,108.8,,,percent of total billed charges,,,34.56,,,percent of total billed charges,,,88.06,,,percent of total billed charges,,,86.14,,,percent of total billed charges,,,108.16,,,percent of total billed charges,,,,,,,,,111.36,,,percent of total billed charges,,,111.36,,,percent of total billed charges,,,108.8,,,percent of total billed charges,,,122.88,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,115.2,,,percent of total billed charges,,,,,,,,,119.04,,,percent of total billed charges,,,121.6,,,percent of total billed charges,,,,,,,,,,,,,,,128,,,fee schedule,,,128,,,fee schedule,,,128,,,fee schedule,,,,,,,,,99.97,,,percent of total billed charges,,,116.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR INTESTINE SM STUDY CNT SINGLE,3266079,CDM,320,RC,74250,CPT,,,,,,inpatient,facility,,,256,107.52,217.6,245.76,,217.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR INTESTINE SM STUDY CNT SINGLE,3266079,CDM,320,RC,74250,CPT,,,,,,outpatient,facility,,,256,107.52,69.12,245.76,,217.6,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,176.13,,,percent of total billed charges,,,172.29,,,percent of total billed charges,,,216.32,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,217.6,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,199.94,,,percent of total billed charges,,,232.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR INTESTINE SM STUDY CNT SINGLE,3266079,CDM,320,RC,74250,CPT,5571,APC,,,,outpatient,facility,,,256,256,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR INTESTINE SM STUDY CNT DOUBLE,3266087,CDM,320,RC,74251,CPT,,,,,,inpatient,facility,,,983,412.86,835.55,943.68,,835.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,855.21,,,percent of total billed charges,,,,,,,,,884.7,,,percent of total billed charges,,,943.68,,,percent of total billed charges,,,933.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,914.19,,,percent of total billed charges,,,933.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR INTESTINE SM STUDY CNT DOUBLE,3266087,CDM,320,RC,74251,CPT,,,,,,outpatient,facility,,,983,412.86,183.74,943.68,,835.55,,,percent of total billed charges,,,265.41,,,percent of total billed charges,,,676.3,,,percent of total billed charges,,,661.56,,,percent of total billed charges,,,830.63,,,percent of total billed charges,,,,,,,,,855.21,,,percent of total billed charges,,,855.21,,,percent of total billed charges,,,835.55,,,percent of total billed charges,,,943.68,,,percent of total billed charges,,,933.85,,,percent of total billed charges,,,,,,,,,884.7,,,percent of total billed charges,,,,,,,,,914.19,,,percent of total billed charges,,,933.85,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,767.72,,,percent of total billed charges,,,894.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR INTESTINE SM STUDY CNT DOUBLE,3266087,CDM,320,RC,74251,CPT,5571,APC,,,,outpatient,facility,,,983,983,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR COLON STUDY CNT SINGLE,3266095,CDM,320,RC,74270,CPT,,,,,,inpatient,facility,,,256,107.52,217.6,245.76,,217.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,222.72,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR COLON STUDY CNT SINGLE,3266095,CDM,320,RC,74270,CPT,,,,,,outpatient,facility,,,256,107.52,69.12,245.76,,217.6,,,percent of total billed charges,,,69.12,,,percent of total billed charges,,,176.13,,,percent of total billed charges,,,172.29,,,percent of total billed charges,,,216.32,,,percent of total billed charges,,,,,,,,,222.72,,,percent of total billed charges,,,222.72,,,percent of total billed charges,,,217.6,,,percent of total billed charges,,,245.76,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,230.4,,,percent of total billed charges,,,,,,,,,238.08,,,percent of total billed charges,,,243.2,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,199.94,,,percent of total billed charges,,,232.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR COLON STUDY CNT SINGLE,3266095,CDM,320,RC,74270,CPT,5571,APC,,,,outpatient,facility,,,256,256,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR COLON STUDY CNT DOUBLE,3266103,CDM,320,RC,74280,CPT,,,,,,inpatient,facility,,,359,150.78,305.15,344.64,,305.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,312.33,,,percent of total billed charges,,,,,,,,,323.1,,,percent of total billed charges,,,344.64,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,333.87,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR COLON STUDY CNT DOUBLE,3266103,CDM,320,RC,74280,CPT,,,,,,outpatient,facility,,,359,150.78,96.93,344.64,,305.15,,,percent of total billed charges,,,96.93,,,percent of total billed charges,,,246.99,,,percent of total billed charges,,,241.61,,,percent of total billed charges,,,303.36,,,percent of total billed charges,,,,,,,,,312.33,,,percent of total billed charges,,,312.33,,,percent of total billed charges,,,305.15,,,percent of total billed charges,,,344.64,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,323.1,,,percent of total billed charges,,,,,,,,,333.87,,,percent of total billed charges,,,341.05,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,280.38,,,percent of total billed charges,,,326.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR COLON STUDY CNT DOUBLE,3266103,CDM,320,RC,74280,CPT,5571,APC,,,,outpatient,facility,,,359,359,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV OCCIPITAL GREAT BI,3266210,CDM,361,RC,64405,CPT,,,,,50,inpatient,facility,,,1102,462.84,936.7,1057.92,,936.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,958.74,,,percent of total billed charges,,,,,,,,,991.8,,,percent of total billed charges,,,1057.92,,,percent of total billed charges,,,1046.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1024.86,,,percent of total billed charges,,,1046.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV OCCIPITAL GREAT BI,3266210,CDM,361,RC,64405,CPT,,,,,50,outpatient,facility,,,1102,462.84,297.54,3428,,936.7,,,percent of total billed charges,,,297.54,,,percent of total billed charges,,,758.18,,,percent of total billed charges,,,741.65,,,percent of total billed charges,,,931.19,,,percent of total billed charges,,,,,,,,,958.74,,,percent of total billed charges,,,958.74,,,percent of total billed charges,,,936.7,,,percent of total billed charges,,,1057.92,,,percent of total billed charges,,,1046.9,,,percent of total billed charges,,,,,,,,,991.8,,,percent of total billed charges,,,,,,,,,1024.86,,,percent of total billed charges,,,1046.9,,,percent of total billed charges,,,,,,,,,,,,,,,453.36,,,fee schedule,,,453.36,,,fee schedule,,,444.29,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,1002.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV OCCIPITAL GREAT BI,3266210,CDM,361,RC,64405,CPT,5441,APC,,,50,outpatient,facility,,,1102,1102,221.54,657.36,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,462.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,453.35,,,fee schedule,,,,,,,,,,,,,,,657.36,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",612.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,453.35,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,453.35,,,fee schedule,,,453.35,,,fee schedule,,,221.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV OCCIPITAL GREAT LT,3266228,CDM,361,RC,64405,CPT,,,,,LT  ,inpatient,facility,,,735,308.7,624.75,705.6,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,639.45,,,percent of total billed charges,,,,,,,,,661.5,,,percent of total billed charges,,,705.6,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.55,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV OCCIPITAL GREAT LT,3266228,CDM,361,RC,64405,CPT,,,,,LT  ,outpatient,facility,,,735,308.7,198.45,3428,,624.75,,,percent of total billed charges,,,198.45,,,percent of total billed charges,,,505.68,,,percent of total billed charges,,,494.65,,,percent of total billed charges,,,621.07,,,percent of total billed charges,,,,,,,,,639.45,,,percent of total billed charges,,,639.45,,,percent of total billed charges,,,624.75,,,percent of total billed charges,,,705.6,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,661.5,,,percent of total billed charges,,,,,,,,,683.55,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,668.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV OCCIPITAL GREAT LT,3266228,CDM,361,RC,64405,CPT,5441,APC,,,LT  ,outpatient,facility,,,735,735,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV OCCIPITAL GREAT RT,3266236,CDM,361,RC,64405,CPT,,,,,RT  ,inpatient,facility,,,735,308.7,624.75,705.6,,624.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,639.45,,,percent of total billed charges,,,,,,,,,661.5,,,percent of total billed charges,,,705.6,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,683.55,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV OCCIPITAL GREAT RT,3266236,CDM,361,RC,64405,CPT,,,,,RT  ,outpatient,facility,,,735,308.7,198.45,3428,,624.75,,,percent of total billed charges,,,198.45,,,percent of total billed charges,,,505.68,,,percent of total billed charges,,,494.65,,,percent of total billed charges,,,621.07,,,percent of total billed charges,,,,,,,,,639.45,,,percent of total billed charges,,,639.45,,,percent of total billed charges,,,624.75,,,percent of total billed charges,,,705.6,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,661.5,,,percent of total billed charges,,,,,,,,,683.55,,,percent of total billed charges,,,698.25,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,668.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV OCCIPITAL GREAT RT,3266236,CDM,361,RC,64405,CPT,5441,APC,,,RT  ,outpatient,facility,,,735,735,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV BR PERPH OTHER BI,3266269,CDM,361,RC,64450,CPT,,,,,50,inpatient,facility,,,1381,580.02,1173.85,1325.76,,1173.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1201.47,,,percent of total billed charges,,,,,,,,,1242.9,,,percent of total billed charges,,,1325.76,,,percent of total billed charges,,,1311.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1284.33,,,percent of total billed charges,,,1311.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV BR PERPH OTHER BI,3266269,CDM,361,RC,64450,CPT,,,,,50,outpatient,facility,,,1381,580.02,372.87,3522,,1173.85,,,percent of total billed charges,,,372.87,,,percent of total billed charges,,,950.13,,,percent of total billed charges,,,929.41,,,percent of total billed charges,,,1166.94,,,percent of total billed charges,,,,,,,,,1201.47,,,percent of total billed charges,,,1201.47,,,percent of total billed charges,,,1173.85,,,percent of total billed charges,,,1325.76,,,percent of total billed charges,,,1311.95,,,percent of total billed charges,,,,,,,,,1242.9,,,percent of total billed charges,,,,,,,,,1284.33,,,percent of total billed charges,,,1311.95,,,percent of total billed charges,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,1037.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1256.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV BR PERPH OTHER BI,3266269,CDM,361,RC,64450,CPT,5442,APC,,,50,outpatient,facility,,,1381,1381,525.01,1534.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,1534.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1429,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1058.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,525.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV BR PERPH OTHER LT,3266277,CDM,361,RC,64450,CPT,,,,,LT  ,inpatient,facility,,,921,386.82,782.85,884.16,,782.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.27,,,percent of total billed charges,,,,,,,,,828.9,,,percent of total billed charges,,,884.16,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,856.53,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV BR PERPH OTHER LT,3266277,CDM,361,RC,64450,CPT,,,,,LT  ,outpatient,facility,,,921,386.82,248.67,3522,,782.85,,,percent of total billed charges,,,248.67,,,percent of total billed charges,,,633.65,,,percent of total billed charges,,,619.83,,,percent of total billed charges,,,778.25,,,percent of total billed charges,,,,,,,,,801.27,,,percent of total billed charges,,,801.27,,,percent of total billed charges,,,782.85,,,percent of total billed charges,,,884.16,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,828.9,,,percent of total billed charges,,,,,,,,,856.53,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,838.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV BR PERPH OTHER LT,3266277,CDM,361,RC,64450,CPT,5442,APC,,,LT  ,outpatient,facility,,,921,921,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV BR PERPH OTHER RT,3266285,CDM,361,RC,64450,CPT,,,,,RT  ,inpatient,facility,,,921,386.82,782.85,884.16,,782.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,801.27,,,percent of total billed charges,,,,,,,,,828.9,,,percent of total billed charges,,,884.16,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,856.53,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV BR PERPH OTHER RT,3266285,CDM,361,RC,64450,CPT,,,,,RT  ,outpatient,facility,,,921,386.82,248.67,3522,,782.85,,,percent of total billed charges,,,248.67,,,percent of total billed charges,,,633.65,,,percent of total billed charges,,,619.83,,,percent of total billed charges,,,778.25,,,percent of total billed charges,,,,,,,,,801.27,,,percent of total billed charges,,,801.27,,,percent of total billed charges,,,782.85,,,percent of total billed charges,,,884.16,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,828.9,,,percent of total billed charges,,,,,,,,,856.53,,,percent of total billed charges,,,874.95,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,838.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV BR PERPH OTHER RT,3266285,CDM,361,RC,64450,CPT,5442,APC,,,RT  ,outpatient,facility,,,921,921,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PUNCT LUMBAR DIAGNOSTIC W FL CT GD,3266293,CDM,361,RC,62328,CPT,,,,,,inpatient,facility,,,2099,881.58,1784.15,2015.04,,1784.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1826.13,,,percent of total billed charges,,,,,,,,,1889.1,,,percent of total billed charges,,,2015.04,,,percent of total billed charges,,,1994.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1952.07,,,percent of total billed charges,,,1994.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCT LUMBAR DIAGNOSTIC W FL CT GD,3266293,CDM,361,RC,62328,CPT,,,,,,outpatient,facility,,,2099,881.58,566.73,3522,,1784.15,,,percent of total billed charges,,,566.73,,,percent of total billed charges,,,1444.11,,,percent of total billed charges,,,1412.63,,,percent of total billed charges,,,1773.65,,,percent of total billed charges,,,,,,,,,1826.13,,,percent of total billed charges,,,1826.13,,,percent of total billed charges,,,1784.15,,,percent of total billed charges,,,2015.04,,,percent of total billed charges,,,1994.05,,,percent of total billed charges,,,,,,,,,1889.1,,,percent of total billed charges,,,,,,,,,1952.07,,,percent of total billed charges,,,1994.05,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1910.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCT LUMBAR DIAGNOSTIC W FL CT GD,3266293,CDM,361,RC,62328,CPT,5442,APC,,,,outpatient,facility,,,2099,2099,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PUNCT SPINE THER DRN CSF W FL CT GD,3266301,CDM,361,RC,62329,CPT,,,,,,inpatient,facility,,,2602,1092.84,2211.7,2497.92,,2211.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2263.74,,,percent of total billed charges,,,,,,,,,2341.8,,,percent of total billed charges,,,2497.92,,,percent of total billed charges,,,2471.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2419.86,,,percent of total billed charges,,,2471.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PUNCT SPINE THER DRN CSF W FL CT GD,3266301,CDM,361,RC,62329,CPT,,,,,,outpatient,facility,,,2602,1092.84,691.57,3522,,2211.7,,,percent of total billed charges,,,702.54,,,percent of total billed charges,,,1790.18,,,percent of total billed charges,,,1751.15,,,percent of total billed charges,,,2198.69,,,percent of total billed charges,,,,,,,,,2263.74,,,percent of total billed charges,,,2263.74,,,percent of total billed charges,,,2211.7,,,percent of total billed charges,,,2497.92,,,percent of total billed charges,,,2471.9,,,percent of total billed charges,,,,,,,,,2341.8,,,percent of total billed charges,,,,,,,,,2419.86,,,percent of total billed charges,,,2471.9,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2367.82,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PUNCT SPINE THER DRN CSF W FL CT GD,3266301,CDM,361,RC,62329,CPT,5442,APC,,,,outpatient,facility,,,2602,2602,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
XR ESOPHAGUS STUDY CNT DOUBLE,3266335,CDM,320,RC,74221,CPT,,,,,,inpatient,facility,,,287,120.54,243.95,275.52,,243.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,249.69,,,percent of total billed charges,,,,,,,,,258.3,,,percent of total billed charges,,,275.52,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,266.91,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
XR ESOPHAGUS STUDY CNT DOUBLE,3266335,CDM,320,RC,74221,CPT,,,,,,outpatient,facility,,,287,120.54,77.49,275.52,,243.95,,,percent of total billed charges,,,77.49,,,percent of total billed charges,,,197.46,,,percent of total billed charges,,,193.15,,,percent of total billed charges,,,242.51,,,percent of total billed charges,,,,,,,,,249.69,,,percent of total billed charges,,,249.69,,,percent of total billed charges,,,243.95,,,percent of total billed charges,,,275.52,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,258.3,,,percent of total billed charges,,,,,,,,,266.91,,,percent of total billed charges,,,272.65,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,224.15,,,percent of total billed charges,,,261.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
XR ESOPHAGUS STUDY CNT DOUBLE,3266335,CDM,320,RC,74221,CPT,5571,APC,,,,outpatient,facility,,,287,287,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ABL RF JOINT SI INCL IMG GD BI,3266418,CDM,361,RC,64625,CPT,,,,,50,inpatient,facility,,,3733,1567.86,3173.05,3583.68,,3173.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3247.71,,,percent of total billed charges,,,,,,,,,3359.7,,,percent of total billed charges,,,3583.68,,,percent of total billed charges,,,3546.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3471.69,,,percent of total billed charges,,,3546.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ABL RF JOINT SI INCL IMG GD BI,3266418,CDM,361,RC,64625,CPT,,,,,50,outpatient,facility,,,3733,1567.86,1007.91,11510,,3173.05,,,percent of total billed charges,,,1007.91,,,percent of total billed charges,,,2568.3,,,percent of total billed charges,,,2512.31,,,percent of total billed charges,,,3154.38,,,percent of total billed charges,,,,,,,,,3247.71,,,percent of total billed charges,,,3247.71,,,percent of total billed charges,,,3173.05,,,percent of total billed charges,,,3583.68,,,percent of total billed charges,,,3546.35,,,percent of total billed charges,,,,,,,,,3359.7,,,percent of total billed charges,,,,,,,,,3471.69,,,percent of total billed charges,,,3546.35,,,percent of total billed charges,,,,,,,,,,,,,,,3733,,,fee schedule,,,3733,,,fee schedule,,,3733,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,3397.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ABL RF JOINT SI INCL IMG GD BI,3266418,CDM,361,RC,64625,CPT,5431,APC,,,50,outpatient,facility,,,3733,3733,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ABL RF JOINT SI INCL IMG GD LT,3266426,CDM,361,RC,64625,CPT,,,,,LT  ,inpatient,facility,,,2489,1045.38,2115.65,2389.44,,2115.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2165.43,,,percent of total billed charges,,,,,,,,,2240.1,,,percent of total billed charges,,,2389.44,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2314.77,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ABL RF JOINT SI INCL IMG GD LT,3266426,CDM,361,RC,64625,CPT,,,,,LT  ,outpatient,facility,,,2489,1045.38,672.03,11510,,2115.65,,,percent of total billed charges,,,672.03,,,percent of total billed charges,,,1712.43,,,percent of total billed charges,,,1675.1,,,percent of total billed charges,,,2103.2,,,percent of total billed charges,,,,,,,,,2165.43,,,percent of total billed charges,,,2165.43,,,percent of total billed charges,,,2115.65,,,percent of total billed charges,,,2389.44,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,2240.1,,,percent of total billed charges,,,,,,,,,2314.77,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,,,,,,,2489,,,fee schedule,,,2489,,,fee schedule,,,2489,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2264.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ABL RF JOINT SI INCL IMG GD LT,3266426,CDM,361,RC,64625,CPT,5431,APC,,,LT  ,outpatient,facility,,,2489,2489,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ABL RF JOINT SI INCL IMG GD RT,3266434,CDM,361,RC,64625,CPT,,,,,RT  ,inpatient,facility,,,2489,1045.38,2115.65,2389.44,,2115.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2165.43,,,percent of total billed charges,,,,,,,,,2240.1,,,percent of total billed charges,,,2389.44,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2314.77,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ABL RF JOINT SI INCL IMG GD RT,3266434,CDM,361,RC,64625,CPT,,,,,RT  ,outpatient,facility,,,2489,1045.38,672.03,11510,,2115.65,,,percent of total billed charges,,,672.03,,,percent of total billed charges,,,1712.43,,,percent of total billed charges,,,1675.1,,,percent of total billed charges,,,2103.2,,,percent of total billed charges,,,,,,,,,2165.43,,,percent of total billed charges,,,2165.43,,,percent of total billed charges,,,2115.65,,,percent of total billed charges,,,2389.44,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,2240.1,,,percent of total billed charges,,,,,,,,,2314.77,,,percent of total billed charges,,,2364.55,,,percent of total billed charges,,,,,,,,,,,,,,,2489,,,fee schedule,,,2489,,,fee schedule,,,2489,,,fee schedule,,,,,,,,,11510,,,percent of total billed charges,,,2264.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ABL RF JOINT SI INCL IMG GD RT,3266434,CDM,361,RC,64625,CPT,5431,APC,,,RT  ,outpatient,facility,,,2489,2489,976.42,2856.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2009.64,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1970.24,,,fee schedule,,,,,,,,,,,,,,,2856.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2659.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1970.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1970.24,,,fee schedule,,,1970.24,,,fee schedule,,,976.42,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DRN PERICARD PERC WO CONG CARD 6 PLUSY,3266566,CDM,361,RC,33017,CPT,,,,,,inpatient,facility,,,5629,2364.18,4784.65,5403.84,,4784.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4897.23,,,percent of total billed charges,,,,,,,,,5066.1,,,percent of total billed charges,,,5403.84,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5234.97,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN PERICARD PERC WO CONG CARD 6 PLUSY,3266566,CDM,361,RC,33017,CPT,,,,,,outpatient,facility,,,5629,2364.18,1519.83,5629,,4784.65,,,percent of total billed charges,,,1519.83,,,percent of total billed charges,,,3872.75,,,percent of total billed charges,,,3788.32,,,percent of total billed charges,,,4756.51,,,percent of total billed charges,,,,,,,,,4897.23,,,percent of total billed charges,,,4897.23,,,percent of total billed charges,,,4784.65,,,percent of total billed charges,,,5403.84,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,5066.1,,,percent of total billed charges,,,,,,,,,5234.97,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,,,,,,,5629,,,fee schedule,,,5629,,,fee schedule,,,5629,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,5122.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DRN PERICARD PERC WO CONG CARD 0 5Y,3266582,CDM,361,RC,33018,CPT,,,,,,inpatient,facility,,,5629,2364.18,4784.65,5403.84,,4784.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4897.23,,,percent of total billed charges,,,,,,,,,5066.1,,,percent of total billed charges,,,5403.84,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5234.97,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DRN PERICARD PERC WO CONG CARD 0 5Y,3266582,CDM,361,RC,33018,CPT,,,,,,outpatient,facility,,,5629,2364.18,1519.83,5629,,4784.65,,,percent of total billed charges,,,1519.83,,,percent of total billed charges,,,3872.75,,,percent of total billed charges,,,3788.32,,,percent of total billed charges,,,4756.51,,,percent of total billed charges,,,,,,,,,4897.23,,,percent of total billed charges,,,4897.23,,,percent of total billed charges,,,4784.65,,,percent of total billed charges,,,5403.84,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,5066.1,,,percent of total billed charges,,,,,,,,,5234.97,,,percent of total billed charges,,,5347.55,,,percent of total billed charges,,,,,,,,,,,,,,,5629,,,fee schedule,,,5629,,,fee schedule,,,5629,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,5122.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD NP UNI,3266822,CDM,361,RC,20604,CPT,,,,,,inpatient,facility,,,581,244.02,493.85,557.76,,493.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.47,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD NP UNI,3266822,CDM,361,RC,20604,CPT,,,,,,outpatient,facility,,,581,244.02,156.87,3428,,493.85,,,percent of total billed charges,,,156.87,,,percent of total billed charges,,,399.73,,,percent of total billed charges,,,391.01,,,percent of total billed charges,,,490.94,,,percent of total billed charges,,,,,,,,,505.47,,,percent of total billed charges,,,505.47,,,percent of total billed charges,,,493.85,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,296.2,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,528.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ASP AND INJ JT BUR SM W US GD NP UNI,3266822,CDM,361,RC,20604,CPT,5441,APC,,,,outpatient,facility,,,581,581,147.69,438.25,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,308.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,302.24,,,fee schedule,,,,,,,,,,,,,,,438.25,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",408.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,302.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,302.24,,,fee schedule,,,302.24,,,fee schedule,,,147.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV FEMORAL W IMG BI,3267010,CDM,361,RC,64447,CPT,,,,,50,inpatient,facility,,,2139,898.38,1818.15,2053.44,,1818.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1860.93,,,percent of total billed charges,,,,,,,,,1925.1,,,percent of total billed charges,,,2053.44,,,percent of total billed charges,,,2032.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1989.27,,,percent of total billed charges,,,2032.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV FEMORAL W IMG BI,3267010,CDM,361,RC,64447,CPT,,,,,50,outpatient,facility,,,2139,898.38,577.53,3522,,1818.15,,,percent of total billed charges,,,577.53,,,percent of total billed charges,,,1471.63,,,percent of total billed charges,,,1439.55,,,percent of total billed charges,,,1807.45,,,percent of total billed charges,,,,,,,,,1860.93,,,percent of total billed charges,,,1860.93,,,percent of total billed charges,,,1818.15,,,percent of total billed charges,,,2053.44,,,percent of total billed charges,,,2032.05,,,percent of total billed charges,,,,,,,,,1925.1,,,percent of total billed charges,,,,,,,,,1989.27,,,percent of total billed charges,,,2032.05,,,percent of total billed charges,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,1037.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1946.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV FEMORAL W IMG BI,3267010,CDM,361,RC,64447,CPT,5442,APC,,,50,outpatient,facility,,,2139,2139,525.01,1534.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,1534.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1429,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1058.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,525.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV FEMORAL W IMG LT,3267028,CDM,361,RC,64447,CPT,,,,,LT  ,inpatient,facility,,,1426,598.92,1212.1,1368.96,,1212.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1240.62,,,percent of total billed charges,,,,,,,,,1283.4,,,percent of total billed charges,,,1368.96,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1326.18,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV FEMORAL W IMG LT,3267028,CDM,361,RC,64447,CPT,,,,,LT  ,outpatient,facility,,,1426,598.92,385.02,3522,,1212.1,,,percent of total billed charges,,,385.02,,,percent of total billed charges,,,981.09,,,percent of total billed charges,,,959.7,,,percent of total billed charges,,,1204.97,,,percent of total billed charges,,,,,,,,,1240.62,,,percent of total billed charges,,,1240.62,,,percent of total billed charges,,,1212.1,,,percent of total billed charges,,,1368.96,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,1283.4,,,percent of total billed charges,,,,,,,,,1326.18,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1297.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV FEMORAL W IMG LT,3267028,CDM,361,RC,64447,CPT,5442,APC,,,LT  ,outpatient,facility,,,1426,1426,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV FEMORAL W IMG RT,3267036,CDM,361,RC,64447,CPT,,,,,RT  ,inpatient,facility,,,1426,598.92,1212.1,1368.96,,1212.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1240.62,,,percent of total billed charges,,,,,,,,,1283.4,,,percent of total billed charges,,,1368.96,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1326.18,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV FEMORAL W IMG RT,3267036,CDM,361,RC,64447,CPT,,,,,RT  ,outpatient,facility,,,1426,598.92,385.02,3522,,1212.1,,,percent of total billed charges,,,385.02,,,percent of total billed charges,,,981.09,,,percent of total billed charges,,,959.7,,,percent of total billed charges,,,1204.97,,,percent of total billed charges,,,,,,,,,1240.62,,,percent of total billed charges,,,1240.62,,,percent of total billed charges,,,1212.1,,,percent of total billed charges,,,1368.96,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,1283.4,,,percent of total billed charges,,,,,,,,,1326.18,,,percent of total billed charges,,,1354.7,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1297.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV FEMORAL W IMG RT,3267036,CDM,361,RC,64447,CPT,5442,APC,,,RT  ,outpatient,facility,,,1426,1426,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV INTRCST LVL SGL BI,3267242,CDM,361,RC,64420,CPT,,,,,50,inpatient,facility,,,1964,824.88,1669.4,1885.44,,1669.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1708.68,,,percent of total billed charges,,,,,,,,,1767.6,,,percent of total billed charges,,,1885.44,,,percent of total billed charges,,,1865.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1826.52,,,percent of total billed charges,,,1865.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL SGL BI,3267242,CDM,361,RC,64420,CPT,,,,,50,outpatient,facility,,,1964,824.88,530.28,3522,,1669.4,,,percent of total billed charges,,,530.28,,,percent of total billed charges,,,1351.23,,,percent of total billed charges,,,1321.77,,,percent of total billed charges,,,1659.58,,,percent of total billed charges,,,,,,,,,1708.68,,,percent of total billed charges,,,1708.68,,,percent of total billed charges,,,1669.4,,,percent of total billed charges,,,1885.44,,,percent of total billed charges,,,1865.8,,,percent of total billed charges,,,,,,,,,1767.6,,,percent of total billed charges,,,,,,,,,1826.52,,,percent of total billed charges,,,1865.8,,,percent of total billed charges,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,1037.35,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1787.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL SGL BI,3267242,CDM,361,RC,64420,CPT,5442,APC,,,50,outpatient,facility,,,1964,1964,525.01,1534.85,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1079.69,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1058.52,,,fee schedule,,,,,,,,,,,,,,,1534.85,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1429,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1058.52,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1058.52,,,fee schedule,,,1058.52,,,fee schedule,,,525.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV INTRCST LVL SGL RT,3267259,CDM,361,RC,64420,CPT,,,,,RT  ,inpatient,facility,,,1309,549.78,1112.65,1256.64,,1112.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.83,,,percent of total billed charges,,,,,,,,,1178.1,,,percent of total billed charges,,,1256.64,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1217.37,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL SGL RT,3267259,CDM,361,RC,64420,CPT,,,,,RT  ,outpatient,facility,,,1309,549.78,353.43,3522,,1112.65,,,percent of total billed charges,,,353.43,,,percent of total billed charges,,,900.59,,,percent of total billed charges,,,880.96,,,percent of total billed charges,,,1106.11,,,percent of total billed charges,,,,,,,,,1138.83,,,percent of total billed charges,,,1138.83,,,percent of total billed charges,,,1112.65,,,percent of total billed charges,,,1256.64,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,1178.1,,,percent of total billed charges,,,,,,,,,1217.37,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1191.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL SGL RT,3267259,CDM,361,RC,64420,CPT,5442,APC,,,RT  ,outpatient,facility,,,1309,1309,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV INTRCST LVL SGL LT,3267267,CDM,361,RC,64420,CPT,,,,,LT  ,inpatient,facility,,,1309,549.78,1112.65,1256.64,,1112.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1138.83,,,percent of total billed charges,,,,,,,,,1178.1,,,percent of total billed charges,,,1256.64,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1217.37,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL SGL LT,3267267,CDM,361,RC,64420,CPT,,,,,LT  ,outpatient,facility,,,1309,549.78,353.43,3522,,1112.65,,,percent of total billed charges,,,353.43,,,percent of total billed charges,,,900.59,,,percent of total billed charges,,,880.96,,,percent of total billed charges,,,1106.11,,,percent of total billed charges,,,,,,,,,1138.83,,,percent of total billed charges,,,1138.83,,,percent of total billed charges,,,1112.65,,,percent of total billed charges,,,1256.64,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,1178.1,,,percent of total billed charges,,,,,,,,,1217.37,,,percent of total billed charges,,,1243.55,,,percent of total billed charges,,,,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,691.57,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1191.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL SGL LT,3267267,CDM,361,RC,64420,CPT,5442,APC,,,LT  ,outpatient,facility,,,1309,1309,350,1023.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,719.79,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,705.68,,,fee schedule,,,,,,,,,,,,,,,1023.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",952.67,,,fee schedule,,,,,,,,,,,,,,,,,,,,,705.68,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,705.68,,,fee schedule,,,705.68,,,fee schedule,,,350,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV INTRCST LVL ADD BI,3267275,CDM,361,RC,64421,CPT,,,,,50,inpatient,facility,,,2690,1129.8,2286.5,2582.4,,2286.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2340.3,,,percent of total billed charges,,,,,,,,,2421,,,percent of total billed charges,,,2582.4,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2501.7,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL ADD BI,3267275,CDM,361,RC,64421,CPT,,,,,50,outpatient,facility,,,2690,1129.8,726.3,3522,,2286.5,,,percent of total billed charges,,,726.3,,,percent of total billed charges,,,1850.72,,,percent of total billed charges,,,1810.37,,,percent of total billed charges,,,2273.05,,,percent of total billed charges,,,,,,,,,2340.3,,,percent of total billed charges,,,2340.3,,,percent of total billed charges,,,2286.5,,,percent of total billed charges,,,2582.4,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,2421,,,percent of total billed charges,,,,,,,,,2501.7,,,percent of total billed charges,,,2555.5,,,percent of total billed charges,,,,,,,,,,,,,,,1395.17,,,fee schedule,,,1395.17,,,fee schedule,,,1367.27,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,2447.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL ADD BI,3267275,CDM,361,RC,64421,CPT,5443,APC,,,50,outpatient,facility,,,2690,2690,694.36,2022.98,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1423.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1395.16,,,fee schedule,,,,,,,,,,,,,,,2022.98,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1883.47,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1395.16,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1395.16,,,fee schedule,,,1395.16,,,fee schedule,,,694.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV INTRCST LVL ADD RT,3267283,CDM,361,RC,64421,CPT,,,,,RT  ,inpatient,facility,,,1793,753.06,1524.05,1721.28,,1524.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1559.91,,,percent of total billed charges,,,,,,,,,1613.7,,,percent of total billed charges,,,1721.28,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1667.49,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL ADD RT,3267283,CDM,361,RC,64421,CPT,,,,,RT  ,outpatient,facility,,,1793,753.06,484.11,3522,,1524.05,,,percent of total billed charges,,,484.11,,,percent of total billed charges,,,1233.58,,,percent of total billed charges,,,1206.69,,,percent of total billed charges,,,1515.09,,,percent of total billed charges,,,,,,,,,1559.91,,,percent of total billed charges,,,1559.91,,,percent of total billed charges,,,1524.05,,,percent of total billed charges,,,1721.28,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,1613.7,,,percent of total billed charges,,,,,,,,,1667.49,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1631.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL ADD RT,3267283,CDM,361,RC,64421,CPT,5443,APC,,,RT  ,outpatient,facility,,,1793,1793,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ S ANES NRV INTRCST LVL ADD LT,3267291,CDM,361,RC,64421,CPT,,,,,LT  ,inpatient,facility,,,1793,753.06,1524.05,1721.28,,1524.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1559.91,,,percent of total billed charges,,,,,,,,,1613.7,,,percent of total billed charges,,,1721.28,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1667.49,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL ADD LT,3267291,CDM,361,RC,64421,CPT,,,,,LT  ,outpatient,facility,,,1793,753.06,484.11,3522,,1524.05,,,percent of total billed charges,,,484.11,,,percent of total billed charges,,,1233.58,,,percent of total billed charges,,,1206.69,,,percent of total billed charges,,,1515.09,,,percent of total billed charges,,,,,,,,,1559.91,,,percent of total billed charges,,,1559.91,,,percent of total billed charges,,,1524.05,,,percent of total billed charges,,,1721.28,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,1613.7,,,percent of total billed charges,,,,,,,,,1667.49,,,percent of total billed charges,,,1703.35,,,percent of total billed charges,,,,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,911.51,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1631.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ S ANES NRV INTRCST LVL ADD LT,3267291,CDM,361,RC,64421,CPT,5443,APC,,,LT  ,outpatient,facility,,,1793,1793,462.91,1348.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,930.11,,,fee schedule,,,,,,,,,,,,,,,1348.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1255.65,,,fee schedule,,,,,,,,,,,,,,,,,,,,,930.11,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,930.11,,,fee schedule,,,930.11,,,fee schedule,,,462.91,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
EXCHG TUBE CHEST VIA WIRE,3283330,CDM,361,RC,32999,CPT,,,,,,inpatient,facility,,,727,305.34,617.95,697.92,,617.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,632.49,,,percent of total billed charges,,,,,,,,,654.3,,,percent of total billed charges,,,697.92,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,676.11,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
EXCHG TUBE CHEST VIA WIRE,3283330,CDM,361,RC,32999,CPT,,,,,,outpatient,facility,,,727,305.34,196.29,3522,,617.95,,,percent of total billed charges,,,196.29,,,percent of total billed charges,,,500.18,,,percent of total billed charges,,,489.27,,,percent of total billed charges,,,614.31,,,percent of total billed charges,,,,,,,,,632.49,,,percent of total billed charges,,,632.49,,,percent of total billed charges,,,617.95,,,percent of total billed charges,,,697.92,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,654.3,,,percent of total billed charges,,,,,,,,,676.11,,,percent of total billed charges,,,690.65,,,percent of total billed charges,,,,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,628.23,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,661.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
EXCHG TUBE CHEST VIA WIRE,3283330,CDM,361,RC,32999,CPT,5181,APC,,,,outpatient,facility,,,727,727,508.9,929.52,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,653.87,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,641.05,,,fee schedule,,,,,,,,,,,,,,,929.52,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",865.42,,,fee schedule,,,,,,,,,,,,,,,,,,,,,641.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,641.05,,,fee schedule,,,641.05,,,fee schedule,,,508.9,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INSTILL BLADDER ANTICARCINOGENIC,3305026,CDM,761,RC,51720,CPT,,,,,,inpatient,facility,,,568,238.56,482.8,545.28,,482.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,494.16,,,percent of total billed charges,,,,,,,,,511.2,,,percent of total billed charges,,,545.28,,,percent of total billed charges,,,539.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,528.24,,,percent of total billed charges,,,539.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INSTILL BLADDER ANTICARCINOGENIC,3305026,CDM,761,RC,51720,CPT,,,,,,outpatient,facility,,,568,238.56,153.36,697.07,,482.8,,,percent of total billed charges,,,153.36,,,percent of total billed charges,,,390.78,,,percent of total billed charges,,,382.26,,,percent of total billed charges,,,479.96,,,percent of total billed charges,,,,,,,,,494.16,,,percent of total billed charges,,,494.16,,,percent of total billed charges,,,482.8,,,percent of total billed charges,,,545.28,,,percent of total billed charges,,,539.6,,,percent of total billed charges,,,,,,,,,511.2,,,percent of total billed charges,,,,,,,,,528.24,,,percent of total billed charges,,,539.6,,,percent of total billed charges,,,,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,683.13,,,fee schedule,,,,,,,,,443.61,,,percent of total billed charges,,,516.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INSTILL BLADDER ANTICARCINOGENIC,3305026,CDM,761,RC,51720,CPT,5372,APC,,,,outpatient,facility,,,568,568,339.68,1010.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,711.01,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,697.07,,,fee schedule,,,,,,,,,,,,,,,1010.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",941.04,,,fee schedule,,,,,,,,,,,,,,,,,,,,,697.07,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,697.07,,,fee schedule,,,697.07,,,fee schedule,,,339.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO SUBQ IM NONHORMONAL,3305372,CDM,331,RC,96401,CPT,,,,,,inpatient,facility,,,1083,454.86,920.55,1039.68,,920.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,942.21,,,percent of total billed charges,,,,,,,,,974.7,,,percent of total billed charges,,,1039.68,,,percent of total billed charges,,,1028.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1007.19,,,percent of total billed charges,,,1028.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO SUBQ IM NONHORMONAL,3305372,CDM,331,RC,96401,CPT,,,,,,outpatient,facility,,,1083,454.86,70.45,1039.68,,920.55,,,percent of total billed charges,,,292.41,,,percent of total billed charges,,,745.1,,,percent of total billed charges,,,728.86,,,percent of total billed charges,,,915.13,,,percent of total billed charges,,,,,,,,,942.21,,,percent of total billed charges,,,942.21,,,percent of total billed charges,,,920.55,,,percent of total billed charges,,,1039.68,,,percent of total billed charges,,,1028.85,,,percent of total billed charges,,,,,,,,,974.7,,,percent of total billed charges,,,,,,,,,1007.19,,,percent of total billed charges,,,1028.85,,,percent of total billed charges,,,,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,70.45,,,fee schedule,,,,,,,,,845.82,,,percent of total billed charges,,,985.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO SUBQ IM NONHORMONAL,3305372,CDM,331,RC,96401,CPT,5692,APC,,,,outpatient,facility,,,1083,1083,36.65,104.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,104.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,71.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,36.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO SUBQ IM HORMONAL,3305380,CDM,331,RC,96402,CPT,,,,,,inpatient,facility,,,420,176.4,357,403.2,,357,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,365.4,,,percent of total billed charges,,,,,,,,,378,,,percent of total billed charges,,,403.2,,,percent of total billed charges,,,399,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,390.6,,,percent of total billed charges,,,399,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO SUBQ IM HORMONAL,3305380,CDM,331,RC,96402,CPT,,,,,,outpatient,facility,,,420,176.4,70.45,403.2,,357,,,percent of total billed charges,,,113.4,,,percent of total billed charges,,,288.96,,,percent of total billed charges,,,282.66,,,percent of total billed charges,,,354.9,,,percent of total billed charges,,,,,,,,,365.4,,,percent of total billed charges,,,365.4,,,percent of total billed charges,,,357,,,percent of total billed charges,,,403.2,,,percent of total billed charges,,,399,,,percent of total billed charges,,,,,,,,,378,,,percent of total billed charges,,,,,,,,,390.6,,,percent of total billed charges,,,399,,,percent of total billed charges,,,,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,70.45,,,fee schedule,,,,,,,,,328.02,,,percent of total billed charges,,,382.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO SUBQ IM HORMONAL,3305380,CDM,331,RC,96402,CPT,5692,APC,,,,outpatient,facility,,,420,420,36.65,104.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,104.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,71.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,36.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO IVP DRUG INITIAL,3305398,CDM,331,RC,96409,CPT,,,,,,inpatient,facility,,,388,162.96,329.8,372.48,,329.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.56,,,percent of total billed charges,,,,,,,,,349.2,,,percent of total billed charges,,,372.48,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.84,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO IVP DRUG INITIAL,3305398,CDM,331,RC,96409,CPT,,,,,,outpatient,facility,,,388,162.96,104.76,372.48,,329.8,,,percent of total billed charges,,,104.76,,,percent of total billed charges,,,266.94,,,percent of total billed charges,,,261.12,,,percent of total billed charges,,,327.86,,,percent of total billed charges,,,,,,,,,337.56,,,percent of total billed charges,,,337.56,,,percent of total billed charges,,,329.8,,,percent of total billed charges,,,372.48,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,349.2,,,percent of total billed charges,,,,,,,,,360.84,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,338.68,,,fee schedule,,,,,,,,,303.03,,,percent of total billed charges,,,353.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO IVP DRUG INITIAL,3305398,CDM,331,RC,96409,CPT,5694,APC,,,,outpatient,facility,,,388,388,180.68,501.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,501.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",466.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,345.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,180.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO IVP DRUG ADDL,3305406,CDM,331,RC,96411,CPT,,,,,,inpatient,facility,,,220,92.4,187,211.2,,187,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.4,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,211.2,,,percent of total billed charges,,,209,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,204.6,,,percent of total billed charges,,,209,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO IVP DRUG ADDL,3305406,CDM,331,RC,96411,CPT,,,,,,outpatient,facility,,,220,92.4,59.4,211.2,,187,,,percent of total billed charges,,,59.4,,,percent of total billed charges,,,151.36,,,percent of total billed charges,,,148.06,,,percent of total billed charges,,,185.9,,,percent of total billed charges,,,,,,,,,191.4,,,percent of total billed charges,,,191.4,,,percent of total billed charges,,,187,,,percent of total billed charges,,,211.2,,,percent of total billed charges,,,209,,,percent of total billed charges,,,,,,,,,198,,,percent of total billed charges,,,,,,,,,204.6,,,percent of total billed charges,,,209,,,percent of total billed charges,,,,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,70.45,,,fee schedule,,,,,,,,,171.82,,,percent of total billed charges,,,200.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO IVP DRUG ADDL,3305406,CDM,331,RC,96411,CPT,5692,APC,,,,outpatient,facility,,,220,220,36.65,104.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,104.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,71.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,36.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO INF IV 1ST HR,3305414,CDM,335,RC,96413,CPT,,,,,,inpatient,facility,,,388,162.96,329.8,372.48,,329.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,337.56,,,percent of total billed charges,,,,,,,,,349.2,,,percent of total billed charges,,,372.48,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,360.84,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO INF IV 1ST HR,3305414,CDM,335,RC,96413,CPT,,,,,,outpatient,facility,,,388,162.96,104.76,372.48,,329.8,,,percent of total billed charges,,,104.76,,,percent of total billed charges,,,266.94,,,percent of total billed charges,,,261.12,,,percent of total billed charges,,,327.86,,,percent of total billed charges,,,,,,,,,337.56,,,percent of total billed charges,,,337.56,,,percent of total billed charges,,,329.8,,,percent of total billed charges,,,372.48,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,349.2,,,percent of total billed charges,,,,,,,,,360.84,,,percent of total billed charges,,,368.6,,,percent of total billed charges,,,,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,338.68,,,fee schedule,,,,,,,,,303.03,,,percent of total billed charges,,,353.08,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO INF IV 1ST HR,3305414,CDM,335,RC,96413,CPT,5694,APC,,,,outpatient,facility,,,388,388,180.68,501.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,352.5,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,345.59,,,fee schedule,,,,,,,,,,,,,,,501.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",466.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,345.59,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,345.59,,,fee schedule,,,345.59,,,fee schedule,,,180.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO INF IV ADDL HR,3305422,CDM,335,RC,96415,CPT,,,,,,inpatient,facility,,,80,33.6,68,76.8,,68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,69.6,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO INF IV ADDL HR,3305422,CDM,335,RC,96415,CPT,,,,,,outpatient,facility,,,80,33.6,21.6,76.8,,68,,,percent of total billed charges,,,21.6,,,percent of total billed charges,,,55.04,,,percent of total billed charges,,,53.84,,,percent of total billed charges,,,67.6,,,percent of total billed charges,,,,,,,,,69.6,,,percent of total billed charges,,,69.6,,,percent of total billed charges,,,68,,,percent of total billed charges,,,76.8,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,72,,,percent of total billed charges,,,,,,,,,74.4,,,percent of total billed charges,,,76,,,percent of total billed charges,,,,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,70.45,,,fee schedule,,,,,,,,,62.48,,,percent of total billed charges,,,72.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO INF IV ADDL HR,3305422,CDM,335,RC,96415,CPT,5692,APC,,,,outpatient,facility,,,80,80,36.65,104.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,104.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,71.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,36.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO INF IV SEQ 1ST HR,3305430,CDM,335,RC,96417,CPT,,,,,,inpatient,facility,,,183,76.86,155.55,175.68,,155.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,159.21,,,percent of total billed charges,,,,,,,,,164.7,,,percent of total billed charges,,,175.68,,,percent of total billed charges,,,173.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,170.19,,,percent of total billed charges,,,173.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO INF IV SEQ 1ST HR,3305430,CDM,335,RC,96417,CPT,,,,,,outpatient,facility,,,183,76.86,49.41,175.68,,155.55,,,percent of total billed charges,,,49.41,,,percent of total billed charges,,,125.9,,,percent of total billed charges,,,123.16,,,percent of total billed charges,,,154.63,,,percent of total billed charges,,,,,,,,,159.21,,,percent of total billed charges,,,159.21,,,percent of total billed charges,,,155.55,,,percent of total billed charges,,,175.68,,,percent of total billed charges,,,173.85,,,percent of total billed charges,,,,,,,,,164.7,,,percent of total billed charges,,,,,,,,,170.19,,,percent of total billed charges,,,173.85,,,percent of total billed charges,,,,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,70.45,,,fee schedule,,,,,,,,,142.92,,,percent of total billed charges,,,166.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO INF IV SEQ 1ST HR,3305430,CDM,335,RC,96417,CPT,5692,APC,,,,outpatient,facility,,,183,183,36.65,104.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,104.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,71.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,36.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO INTRALESIONAL LSN 1 7,3305570,CDM,331,RC,96405,CPT,,,,,,inpatient,facility,,,415,174.3,352.75,398.4,,352.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,361.05,,,percent of total billed charges,,,,,,,,,373.5,,,percent of total billed charges,,,398.4,,,percent of total billed charges,,,394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,385.95,,,percent of total billed charges,,,394.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO INTRALESIONAL LSN 1 7,3305570,CDM,331,RC,96405,CPT,,,,,,outpatient,facility,,,415,174.3,70.45,398.4,,352.75,,,percent of total billed charges,,,112.05,,,percent of total billed charges,,,285.52,,,percent of total billed charges,,,279.29,,,percent of total billed charges,,,350.68,,,percent of total billed charges,,,,,,,,,361.05,,,percent of total billed charges,,,361.05,,,percent of total billed charges,,,352.75,,,percent of total billed charges,,,398.4,,,percent of total billed charges,,,394.25,,,percent of total billed charges,,,,,,,,,373.5,,,percent of total billed charges,,,,,,,,,385.95,,,percent of total billed charges,,,394.25,,,percent of total billed charges,,,,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,70.45,,,fee schedule,,,,,,,,,324.11,,,percent of total billed charges,,,377.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO INTRALESIONAL LSN 1 7,3305570,CDM,331,RC,96405,CPT,5692,APC,,,,outpatient,facility,,,415,415,36.65,104.24,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.33,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,71.89,,,fee schedule,,,,,,,,,,,,,,,104.24,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",97.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,71.89,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,71.89,,,fee schedule,,,71.89,,,fee schedule,,,36.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CHEMO INTRALESIONAL LSN 8 PLUS,3305588,CDM,331,RC,96406,CPT,,,,,,inpatient,facility,,,648,272.16,550.8,622.08,,550.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,563.76,,,percent of total billed charges,,,,,,,,,583.2,,,percent of total billed charges,,,622.08,,,percent of total billed charges,,,615.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,602.64,,,percent of total billed charges,,,615.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CHEMO INTRALESIONAL LSN 8 PLUS,3305588,CDM,331,RC,96406,CPT,,,,,,outpatient,facility,,,648,272.16,174.96,622.08,,550.8,,,percent of total billed charges,,,174.96,,,percent of total billed charges,,,445.82,,,percent of total billed charges,,,436.1,,,percent of total billed charges,,,547.56,,,percent of total billed charges,,,,,,,,,563.76,,,percent of total billed charges,,,563.76,,,percent of total billed charges,,,550.8,,,percent of total billed charges,,,622.08,,,percent of total billed charges,,,615.6,,,percent of total billed charges,,,,,,,,,583.2,,,percent of total billed charges,,,,,,,,,602.64,,,percent of total billed charges,,,615.6,,,percent of total billed charges,,,,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,214.35,,,fee schedule,,,,,,,,,506.09,,,percent of total billed charges,,,589.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CHEMO INTRALESIONAL LSN 8 PLUS,3305588,CDM,331,RC,96406,CPT,5693,APC,,,,outpatient,facility,,,648,648,112.21,317.14,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,223.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,218.72,,,fee schedule,,,,,,,,,,,,,,,317.14,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",295.27,,,fee schedule,,,,,,,,,,,,,,,,,,,,,218.72,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,218.72,,,fee schedule,,,218.72,,,fee schedule,,,112.21,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ROOM AND BOARD ICU,33274,CDM,200,RC,,,,,,,,inpatient,facility,,,6600,2772,5610,6600,,5610,,,percent of total billed charges,,,,,,,,,6600,,,case rate,,,6600,,,case rate,,,,,,,,,,,,,,,5742,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,6336,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,5940,,,percent of total billed charges,,,,,,,,,6138,,,percent of total billed charges,,,6270,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6600,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,other,,Medicare I/P Reimbursement:    Acute Component Percentages:  DRG Amount: 100%  Operating Outliers: 100%  Operating DSH: 100%  Operating IME: 0%  Federal Capital: 100%  Capital Outliers: 100%  Capital DSH: 100%  Capital IME: 100%  Pass-Through: 100%  Apply Low Volume Adjustment to the DRG payment  Ignore UCP and DSH exclusion with HSP payment  Apply addon to Covid-19 claims  Apply Car T-Cell Adjustment   Use this provider number in place of provider number from claim: 530012   Use this service date in place of service date from claim:     Override standard base with : $   Rehab -  Operating: 100%  DSH: 100%  Outlier: 100%  IME: 100%   Psych -  Blend: 100%  Outlier: 100%  IME: 100%   SNF RUG: 100%   Pediatric Per Diem: 100% If ( Current Amount = 0.00 )   Then:  100.00 % of Gross Charges Adjusted  Manual Review/Entry: Flag for review : Codes without Medicare Rates.      Please Review. ,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN PORT TELETHRPY SPEC,3330529,CDM,333,RC,77321,CPT,,,,,,inpatient,facility,,,972,408.24,826.2,933.12,,826.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,845.64,,,percent of total billed charges,,,,,,,,,874.8,,,percent of total billed charges,,,933.12,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,903.96,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN PORT TELETHRPY SPEC,3330529,CDM,333,RC,77321,CPT,,,,,,outpatient,facility,,,972,408.24,262.44,933.12,,826.2,,,percent of total billed charges,,,262.44,,,percent of total billed charges,,,668.74,,,percent of total billed charges,,,654.16,,,percent of total billed charges,,,821.34,,,percent of total billed charges,,,,,,,,,845.64,,,percent of total billed charges,,,845.64,,,percent of total billed charges,,,826.2,,,percent of total billed charges,,,933.12,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,,,,,,,874.8,,,percent of total billed charges,,,,,,,,,903.96,,,percent of total billed charges,,,923.4,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,759.13,,,percent of total billed charges,,,884.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN PORT TELETHRPY SPEC,3330529,CDM,333,RC,77321,CPT,5612,APC,,,,outpatient,facility,,,972,972,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RAD THER FIELD SIMULAT LVL 01 SMPL,3332061,CDM,333,RC,77280,CPT,,,,,,inpatient,facility,,,885,371.7,752.25,849.6,,752.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,769.95,,,percent of total billed charges,,,,,,,,,796.5,,,percent of total billed charges,,,849.6,,,percent of total billed charges,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,823.05,,,percent of total billed charges,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RAD THER FIELD SIMULAT LVL 01 SMPL,3332061,CDM,333,RC,77280,CPT,,,,,,outpatient,facility,,,885,371.7,135.69,849.6,,752.25,,,percent of total billed charges,,,238.95,,,percent of total billed charges,,,608.88,,,percent of total billed charges,,,595.6,,,percent of total billed charges,,,747.82,,,percent of total billed charges,,,,,,,,,769.95,,,percent of total billed charges,,,769.95,,,percent of total billed charges,,,752.25,,,percent of total billed charges,,,849.6,,,percent of total billed charges,,,840.75,,,percent of total billed charges,,,,,,,,,796.5,,,percent of total billed charges,,,,,,,,,823.05,,,percent of total billed charges,,,840.75,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,691.18,,,percent of total billed charges,,,805.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RAD THER FIELD SIMULAT LVL 01 SMPL,3332061,CDM,333,RC,77280,CPT,5611,APC,,,,outpatient,facility,,,885,885,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RAD THER FIELD SIMULAT LVL 02 INTRM,3332079,CDM,333,RC,77285,CPT,,,,,,inpatient,facility,,,1327,557.34,1127.95,1273.92,,1127.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1154.49,,,percent of total billed charges,,,,,,,,,1194.3,,,percent of total billed charges,,,1273.92,,,percent of total billed charges,,,1260.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1234.11,,,percent of total billed charges,,,1260.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RAD THER FIELD SIMULAT LVL 02 INTRM,3332079,CDM,333,RC,77285,CPT,,,,,,outpatient,facility,,,1327,557.34,358.29,1273.92,,1127.95,,,percent of total billed charges,,,358.29,,,percent of total billed charges,,,912.98,,,percent of total billed charges,,,893.07,,,percent of total billed charges,,,1121.32,,,percent of total billed charges,,,,,,,,,1154.49,,,percent of total billed charges,,,1154.49,,,percent of total billed charges,,,1127.95,,,percent of total billed charges,,,1273.92,,,percent of total billed charges,,,1260.65,,,percent of total billed charges,,,,,,,,,1194.3,,,percent of total billed charges,,,,,,,,,1234.11,,,percent of total billed charges,,,1260.65,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,1036.39,,,percent of total billed charges,,,1207.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RAD THER FIELD SIMULAT LVL 02 INTRM,3332079,CDM,333,RC,77285,CPT,5612,APC,,,,outpatient,facility,,,1327,1327,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RAD THER FIELD SIMULAT LVL 03 CMPLX,3332087,CDM,333,RC,77290,CPT,,,,,,inpatient,facility,,,1701,714.42,1445.85,1632.96,,1445.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1479.87,,,percent of total billed charges,,,,,,,,,1530.9,,,percent of total billed charges,,,1632.96,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1581.93,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RAD THER FIELD SIMULAT LVL 03 CMPLX,3332087,CDM,333,RC,77290,CPT,,,,,,outpatient,facility,,,1701,714.42,369.51,1632.96,,1445.85,,,percent of total billed charges,,,459.27,,,percent of total billed charges,,,1170.29,,,percent of total billed charges,,,1144.77,,,percent of total billed charges,,,1437.35,,,percent of total billed charges,,,,,,,,,1479.87,,,percent of total billed charges,,,1479.87,,,percent of total billed charges,,,1445.85,,,percent of total billed charges,,,1632.96,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,,,,,,,,1530.9,,,percent of total billed charges,,,,,,,,,1581.93,,,percent of total billed charges,,,1615.95,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,1328.48,,,percent of total billed charges,,,1547.91,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RAD THER FIELD SIMULAT LVL 03 CMPLX,3332087,CDM,333,RC,77290,CPT,5612,APC,,,,outpatient,facility,,,1701,1701,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CALC DOSIMETRY RAD BASIC,3332111,CDM,333,RC,77300,CPT,,,,,,inpatient,facility,,,526,220.92,447.1,504.96,,447.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,457.62,,,percent of total billed charges,,,,,,,,,473.4,,,percent of total billed charges,,,504.96,,,percent of total billed charges,,,499.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,489.18,,,percent of total billed charges,,,499.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY RAD BASIC,3332111,CDM,333,RC,77300,CPT,,,,,,outpatient,facility,,,526,220.92,135.69,504.96,,447.1,,,percent of total billed charges,,,142.02,,,percent of total billed charges,,,361.89,,,percent of total billed charges,,,354,,,percent of total billed charges,,,444.47,,,percent of total billed charges,,,,,,,,,457.62,,,percent of total billed charges,,,457.62,,,percent of total billed charges,,,447.1,,,percent of total billed charges,,,504.96,,,percent of total billed charges,,,499.7,,,percent of total billed charges,,,,,,,,,473.4,,,percent of total billed charges,,,,,,,,,489.18,,,percent of total billed charges,,,499.7,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,410.81,,,percent of total billed charges,,,478.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY RAD BASIC,3332111,CDM,333,RC,77300,CPT,5611,APC,,,,outpatient,facility,,,526,526,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLAN IMRT HISTOGRAMS DOSE VOLUME,3332129,CDM,333,RC,77301,CPT,,,,,,inpatient,facility,,,8079,3393.18,6867.15,7755.84,,6867.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7028.73,,,percent of total billed charges,,,,,,,,,7271.1,,,percent of total billed charges,,,7755.84,,,percent of total billed charges,,,7675.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7513.47,,,percent of total billed charges,,,7675.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN IMRT HISTOGRAMS DOSE VOLUME,3332129,CDM,333,RC,77301,CPT,,,,,,outpatient,facility,,,8079,3393.18,1385.66,7755.84,,6867.15,,,percent of total billed charges,,,2181.33,,,percent of total billed charges,,,5558.35,,,percent of total billed charges,,,5437.17,,,percent of total billed charges,,,6826.76,,,percent of total billed charges,,,,,,,,,7028.73,,,percent of total billed charges,,,7028.73,,,percent of total billed charges,,,6867.15,,,percent of total billed charges,,,7755.84,,,percent of total billed charges,,,7675.05,,,percent of total billed charges,,,,,,,,,7271.1,,,percent of total billed charges,,,,,,,,,7513.47,,,percent of total billed charges,,,7675.05,,,percent of total billed charges,,,,,,,,,,,,,,,1413.94,,,fee schedule,,,1413.94,,,fee schedule,,,1385.66,,,fee schedule,,,,,,,,,6309.7,,,percent of total billed charges,,,7351.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN IMRT HISTOGRAMS DOSE VOLUME,3332129,CDM,333,RC,77301,CPT,5613,APC,,,,outpatient,facility,,,8079,8079,728.26,2050.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1413.94,,,fee schedule,,,,,,,,,,,,,,,2050.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1908.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1413.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1413.94,,,fee schedule,,,1413.94,,,fee schedule,,,728.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CALC DOSIMETRY SPEC,3332228,CDM,333,RC,77331,CPT,,,,,,inpatient,facility,,,909,381.78,772.65,872.64,,772.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.83,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY SPEC,3332228,CDM,333,RC,77331,CPT,,,,,,outpatient,facility,,,909,381.78,135.69,872.64,,772.65,,,percent of total billed charges,,,245.43,,,percent of total billed charges,,,625.39,,,percent of total billed charges,,,611.76,,,percent of total billed charges,,,768.11,,,percent of total billed charges,,,,,,,,,790.83,,,percent of total billed charges,,,790.83,,,percent of total billed charges,,,772.65,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,709.93,,,percent of total billed charges,,,827.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY SPEC,3332228,CDM,333,RC,77331,CPT,5611,APC,,,,outpatient,facility,,,909,909,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CALC DOSIMETRY SPEC DIODE,3332236,CDM,333,RC,77331,CPT,,,,,,inpatient,facility,,,909,381.78,772.65,872.64,,772.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.83,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY SPEC DIODE,3332236,CDM,333,RC,77331,CPT,,,,,,outpatient,facility,,,909,381.78,135.69,872.64,,772.65,,,percent of total billed charges,,,245.43,,,percent of total billed charges,,,625.39,,,percent of total billed charges,,,611.76,,,percent of total billed charges,,,768.11,,,percent of total billed charges,,,,,,,,,790.83,,,percent of total billed charges,,,790.83,,,percent of total billed charges,,,772.65,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,709.93,,,percent of total billed charges,,,827.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY SPEC DIODE,3332236,CDM,333,RC,77331,CPT,5611,APC,,,,outpatient,facility,,,909,909,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CALC DOSIMETRY SPEC TLD,3332244,CDM,333,RC,77331,CPT,,,,,,inpatient,facility,,,909,381.78,772.65,872.64,,772.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,790.83,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY SPEC TLD,3332244,CDM,333,RC,77331,CPT,,,,,,outpatient,facility,,,909,381.78,135.69,872.64,,772.65,,,percent of total billed charges,,,245.43,,,percent of total billed charges,,,625.39,,,percent of total billed charges,,,611.76,,,percent of total billed charges,,,768.11,,,percent of total billed charges,,,,,,,,,790.83,,,percent of total billed charges,,,790.83,,,percent of total billed charges,,,772.65,,,percent of total billed charges,,,872.64,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,818.1,,,percent of total billed charges,,,,,,,,,845.37,,,percent of total billed charges,,,863.55,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,709.93,,,percent of total billed charges,,,827.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CALC DOSIMETRY SPEC TLD,3332244,CDM,333,RC,77331,CPT,5611,APC,,,,outpatient,facility,,,909,909,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DEVICE TX DESIGN ANDCONST LVL 01 SMPL,3332251,CDM,333,RC,77332,CPT,,,,,,inpatient,facility,,,535,224.7,454.75,513.6,,454.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,465.45,,,percent of total billed charges,,,,,,,,,481.5,,,percent of total billed charges,,,513.6,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,497.55,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE TX DESIGN ANDCONST LVL 01 SMPL,3332251,CDM,333,RC,77332,CPT,,,,,,outpatient,facility,,,535,224.7,135.69,513.6,,454.75,,,percent of total billed charges,,,144.45,,,percent of total billed charges,,,368.08,,,percent of total billed charges,,,360.05,,,percent of total billed charges,,,452.07,,,percent of total billed charges,,,,,,,,,465.45,,,percent of total billed charges,,,465.45,,,percent of total billed charges,,,454.75,,,percent of total billed charges,,,513.6,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,481.5,,,percent of total billed charges,,,,,,,,,497.55,,,percent of total billed charges,,,508.25,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,417.83,,,percent of total billed charges,,,486.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DEVICE TX DESIGN ANDCONST LVL 01 SMPL,3332251,CDM,333,RC,77332,CPT,5611,APC,,,,outpatient,facility,,,535,535,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DEVICE TX DESIGN ANDCONST LVL 02 INTRM,3332269,CDM,333,RC,77333,CPT,,,,,,inpatient,facility,,,1110,466.2,943.5,1065.6,,943.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,965.7,,,percent of total billed charges,,,,,,,,,999,,,percent of total billed charges,,,1065.6,,,percent of total billed charges,,,1054.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1032.3,,,percent of total billed charges,,,1054.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE TX DESIGN ANDCONST LVL 02 INTRM,3332269,CDM,333,RC,77333,CPT,,,,,,outpatient,facility,,,1110,466.2,135.69,1065.6,,943.5,,,percent of total billed charges,,,299.7,,,percent of total billed charges,,,763.68,,,percent of total billed charges,,,747.03,,,percent of total billed charges,,,937.95,,,percent of total billed charges,,,,,,,,,965.7,,,percent of total billed charges,,,965.7,,,percent of total billed charges,,,943.5,,,percent of total billed charges,,,1065.6,,,percent of total billed charges,,,1054.5,,,percent of total billed charges,,,,,,,,,999,,,percent of total billed charges,,,,,,,,,1032.3,,,percent of total billed charges,,,1054.5,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,866.91,,,percent of total billed charges,,,1010.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DEVICE TX DESIGN ANDCONST LVL 02 INTRM,3332269,CDM,333,RC,77333,CPT,5611,APC,,,,outpatient,facility,,,1110,1110,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DEVICE TX DESIGN ANDCONST LVL 03 CMPLX,3332277,CDM,333,RC,77334,CPT,,,,,,inpatient,facility,,,1305,548.1,1109.25,1252.8,,1109.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1135.35,,,percent of total billed charges,,,,,,,,,1174.5,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1213.65,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE TX DESIGN ANDCONST LVL 03 CMPLX,3332277,CDM,333,RC,77334,CPT,,,,,,outpatient,facility,,,1305,548.1,352.35,1252.8,,1109.25,,,percent of total billed charges,,,352.35,,,percent of total billed charges,,,897.84,,,percent of total billed charges,,,878.26,,,percent of total billed charges,,,1102.72,,,percent of total billed charges,,,,,,,,,1135.35,,,percent of total billed charges,,,1135.35,,,percent of total billed charges,,,1109.25,,,percent of total billed charges,,,1252.8,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,1174.5,,,percent of total billed charges,,,,,,,,,1213.65,,,percent of total billed charges,,,1239.75,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,1019.2,,,percent of total billed charges,,,1187.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DEVICE TX DESIGN ANDCONST LVL 03 CMPLX,3332277,CDM,333,RC,77334,CPT,5612,APC,,,,outpatient,facility,,,1305,1305,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CONSULT PHYSICS MEDICAL CONTINUING,3332285,CDM,333,RC,77336,CPT,,,,,,inpatient,facility,,,907,380.94,770.95,870.72,,770.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,789.09,,,percent of total billed charges,,,,,,,,,816.3,,,percent of total billed charges,,,870.72,,,percent of total billed charges,,,861.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,843.51,,,percent of total billed charges,,,861.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CONSULT PHYSICS MEDICAL CONTINUING,3332285,CDM,333,RC,77336,CPT,,,,,,outpatient,facility,,,907,380.94,135.69,870.72,,770.95,,,percent of total billed charges,,,244.89,,,percent of total billed charges,,,624.02,,,percent of total billed charges,,,610.41,,,percent of total billed charges,,,766.41,,,percent of total billed charges,,,,,,,,,789.09,,,percent of total billed charges,,,789.09,,,percent of total billed charges,,,770.95,,,percent of total billed charges,,,870.72,,,percent of total billed charges,,,861.65,,,percent of total billed charges,,,,,,,,,816.3,,,percent of total billed charges,,,,,,,,,843.51,,,percent of total billed charges,,,861.65,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,708.37,,,percent of total billed charges,,,825.37,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CONSULT PHYSICS MEDICAL CONTINUING,3332285,CDM,333,RC,77336,CPT,5611,APC,,,,outpatient,facility,,,907,907,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CONSULT PHYSICS RAD MEDICAL SPECIAL,3332293,CDM,333,RC,77370,CPT,,,,,,inpatient,facility,,,1414,593.88,1201.9,1357.44,,1201.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1230.18,,,percent of total billed charges,,,,,,,,,1272.6,,,percent of total billed charges,,,1357.44,,,percent of total billed charges,,,1343.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1315.02,,,percent of total billed charges,,,1343.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CONSULT PHYSICS RAD MEDICAL SPECIAL,3332293,CDM,333,RC,77370,CPT,,,,,,outpatient,facility,,,1414,593.88,135.69,1357.44,,1201.9,,,percent of total billed charges,,,381.78,,,percent of total billed charges,,,972.83,,,percent of total billed charges,,,951.62,,,percent of total billed charges,,,1194.83,,,percent of total billed charges,,,,,,,,,1230.18,,,percent of total billed charges,,,1230.18,,,percent of total billed charges,,,1201.9,,,percent of total billed charges,,,1357.44,,,percent of total billed charges,,,1343.3,,,percent of total billed charges,,,,,,,,,1272.6,,,percent of total billed charges,,,,,,,,,1315.02,,,percent of total billed charges,,,1343.3,,,percent of total billed charges,,,,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,135.69,,,fee schedule,,,,,,,,,1104.33,,,percent of total billed charges,,,1286.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CONSULT PHYSICS RAD MEDICAL SPECIAL,3332293,CDM,333,RC,77370,CPT,5611,APC,,,,outpatient,facility,,,1414,1414,72.45,200.77,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,141.23,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,138.46,,,fee schedule,,,,,,,,,,,,,,,200.77,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",186.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,138.46,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,138.46,,,fee schedule,,,138.46,,,fee schedule,,,72.45,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RAD THER IMG S PORT,3332343,CDM,333,RC,77417,CPT,,,,,,inpatient,facility,,,239,100.38,203.15,229.44,,203.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,207.93,,,percent of total billed charges,,,,,,,,,215.1,,,percent of total billed charges,,,229.44,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,222.27,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RAD THER IMG S PORT,3332343,CDM,333,RC,77417,CPT,,,,,,outpatient,facility,,,239,100.38,64.53,239,,203.15,,,percent of total billed charges,,,64.53,,,percent of total billed charges,,,164.43,,,percent of total billed charges,,,160.85,,,percent of total billed charges,,,201.95,,,percent of total billed charges,,,,,,,,,207.93,,,percent of total billed charges,,,207.93,,,percent of total billed charges,,,203.15,,,percent of total billed charges,,,229.44,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,,,,,,,215.1,,,percent of total billed charges,,,,,,,,,222.27,,,percent of total billed charges,,,227.05,,,percent of total billed charges,,,,,,,,,,,,,,,239,,,fee schedule,,,239,,,fee schedule,,,239,,,fee schedule,,,,,,,,,186.66,,,percent of total billed charges,,,217.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROCEDURE TX SPECIAL THRPY RAD,3332376,CDM,333,RC,77470,CPT,,,,,,inpatient,facility,,,2083,874.86,1770.55,1999.68,,1770.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1812.21,,,percent of total billed charges,,,,,,,,,1874.7,,,percent of total billed charges,,,1999.68,,,percent of total billed charges,,,1978.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1937.19,,,percent of total billed charges,,,1978.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PROCEDURE TX SPECIAL THRPY RAD,3332376,CDM,333,RC,77470,CPT,,,,,,outpatient,facility,,,2083,874.86,562.41,1999.68,,1770.55,,,percent of total billed charges,,,562.41,,,percent of total billed charges,,,1433.1,,,percent of total billed charges,,,1401.86,,,percent of total billed charges,,,1760.13,,,percent of total billed charges,,,,,,,,,1812.21,,,percent of total billed charges,,,1812.21,,,percent of total billed charges,,,1770.55,,,percent of total billed charges,,,1999.68,,,percent of total billed charges,,,1978.85,,,percent of total billed charges,,,,,,,,,1874.7,,,percent of total billed charges,,,,,,,,,1937.19,,,percent of total billed charges,,,1978.85,,,percent of total billed charges,,,,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,588.68,,,fee schedule,,,,,,,,,1626.82,,,percent of total billed charges,,,1895.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PROCEDURE TX SPECIAL THRPY RAD,3332376,CDM,333,RC,77470,CPT,5623,APC,,,,outpatient,facility,,,2083,2083,310.97,871,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,871,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",810.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,600.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,310.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
APPL BRACHY INTRACAV LVL 01 SMPL,3332392,CDM,333,RC,77761,CPT,,,,,,inpatient,facility,,,1420,596.4,1207,1363.2,,1207,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1235.4,,,percent of total billed charges,,,,,,,,,1278,,,percent of total billed charges,,,1363.2,,,percent of total billed charges,,,1349,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1320.6,,,percent of total billed charges,,,1349,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
APPL BRACHY INTRACAV LVL 01 SMPL,3332392,CDM,333,RC,77761,CPT,,,,,,outpatient,facility,,,1420,596.4,383.4,1363.2,,1207,,,percent of total billed charges,,,383.4,,,percent of total billed charges,,,976.96,,,percent of total billed charges,,,955.66,,,percent of total billed charges,,,1199.9,,,percent of total billed charges,,,,,,,,,1235.4,,,percent of total billed charges,,,1235.4,,,percent of total billed charges,,,1207,,,percent of total billed charges,,,1363.2,,,percent of total billed charges,,,1349,,,percent of total billed charges,,,,,,,,,1278,,,percent of total billed charges,,,,,,,,,1320.6,,,percent of total billed charges,,,1349,,,percent of total billed charges,,,,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,588.68,,,fee schedule,,,,,,,,,1109.02,,,percent of total billed charges,,,1292.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
APPL BRACHY INTRACAV LVL 01 SMPL,3332392,CDM,333,RC,77761,CPT,5623,APC,,,,outpatient,facility,,,1420,1420,310.97,871,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,871,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",810.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,600.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,310.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
APPL BRACHY INTRACAV LVL 02 INTRM,3332400,CDM,333,RC,77762,CPT,,,,,,inpatient,facility,,,1875,787.5,1593.75,1800,,1593.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1631.25,,,percent of total billed charges,,,,,,,,,1687.5,,,percent of total billed charges,,,1800,,,percent of total billed charges,,,1781.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1743.75,,,percent of total billed charges,,,1781.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
APPL BRACHY INTRACAV LVL 02 INTRM,3332400,CDM,333,RC,77762,CPT,,,,,,outpatient,facility,,,1875,787.5,506.25,1800,,1593.75,,,percent of total billed charges,,,506.25,,,percent of total billed charges,,,1290,,,percent of total billed charges,,,1261.87,,,percent of total billed charges,,,1584.38,,,percent of total billed charges,,,,,,,,,1631.25,,,percent of total billed charges,,,1631.25,,,percent of total billed charges,,,1593.75,,,percent of total billed charges,,,1800,,,percent of total billed charges,,,1781.25,,,percent of total billed charges,,,,,,,,,1687.5,,,percent of total billed charges,,,,,,,,,1743.75,,,percent of total billed charges,,,1781.25,,,percent of total billed charges,,,,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,588.68,,,fee schedule,,,,,,,,,1464.38,,,percent of total billed charges,,,1706.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
APPL BRACHY INTRACAV LVL 02 INTRM,3332400,CDM,333,RC,77762,CPT,5623,APC,,,,outpatient,facility,,,1875,1875,310.97,871,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,871,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",810.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,600.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,310.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
APPL BRACHY INTRACAV LVL 03 CMPLX,3332418,CDM,333,RC,77763,CPT,,,,,,inpatient,facility,,,2679,1125.18,2277.15,2571.84,,2277.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2330.73,,,percent of total billed charges,,,,,,,,,2411.1,,,percent of total billed charges,,,2571.84,,,percent of total billed charges,,,2545.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2491.47,,,percent of total billed charges,,,2545.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
APPL BRACHY INTRACAV LVL 03 CMPLX,3332418,CDM,333,RC,77763,CPT,,,,,,outpatient,facility,,,2679,1125.18,717,2571.84,,2277.15,,,percent of total billed charges,,,723.33,,,percent of total billed charges,,,1843.15,,,percent of total billed charges,,,1802.97,,,percent of total billed charges,,,2263.76,,,percent of total billed charges,,,,,,,,,2330.73,,,percent of total billed charges,,,2330.73,,,percent of total billed charges,,,2277.15,,,percent of total billed charges,,,2571.84,,,percent of total billed charges,,,2545.05,,,percent of total billed charges,,,,,,,,,2411.1,,,percent of total billed charges,,,,,,,,,2491.47,,,percent of total billed charges,,,2545.05,,,percent of total billed charges,,,,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,717,,,fee schedule,,,,,,,,,2092.3,,,percent of total billed charges,,,2437.89,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
APPL BRACHY INTRACAV LVL 03 CMPLX,3332418,CDM,333,RC,77763,CPT,5624,APC,,,,outpatient,facility,,,2679,2679,392.04,1060.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,1060.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",987.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,731.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,392.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
APPL SOURCE RAD INTERSTITIAL CMPLX,3332442,CDM,333,RC,77778,CPT,,,,,,inpatient,facility,,,3968,1666.56,3372.8,3809.28,,3372.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3452.16,,,percent of total billed charges,,,,,,,,,3571.2,,,percent of total billed charges,,,3809.28,,,percent of total billed charges,,,3769.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3690.24,,,percent of total billed charges,,,3769.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
APPL SOURCE RAD INTERSTITIAL CMPLX,3332442,CDM,333,RC,77778,CPT,,,,,,outpatient,facility,,,3968,1666.56,717,3809.28,,3372.8,,,percent of total billed charges,,,1071.36,,,percent of total billed charges,,,2729.98,,,percent of total billed charges,,,2670.46,,,percent of total billed charges,,,3352.96,,,percent of total billed charges,,,,,,,,,3452.16,,,percent of total billed charges,,,3452.16,,,percent of total billed charges,,,3372.8,,,percent of total billed charges,,,3809.28,,,percent of total billed charges,,,3769.6,,,percent of total billed charges,,,,,,,,,3571.2,,,percent of total billed charges,,,,,,,,,3690.24,,,percent of total billed charges,,,3769.6,,,percent of total billed charges,,,,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,717,,,fee schedule,,,,,,,,,3099.01,,,percent of total billed charges,,,3610.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
APPL SOURCE RAD INTERSTITIAL CMPLX,3332442,CDM,333,RC,77778,CPT,5624,APC,,,,outpatient,facility,,,3968,3968,392.04,1060.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,1060.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",987.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,731.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,392.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
SPVN HANDLING LOAD RADIOELEMENT,3332491,CDM,333,RC,77790,CPT,,,,,,inpatient,facility,,,730,306.6,620.5,700.8,,620.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,635.1,,,percent of total billed charges,,,,,,,,,657,,,percent of total billed charges,,,700.8,,,percent of total billed charges,,,693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,678.9,,,percent of total billed charges,,,693.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SPVN HANDLING LOAD RADIOELEMENT,3332491,CDM,333,RC,77790,CPT,,,,,,outpatient,facility,,,730,306.6,197.1,730,,620.5,,,percent of total billed charges,,,197.1,,,percent of total billed charges,,,502.24,,,percent of total billed charges,,,491.29,,,percent of total billed charges,,,616.85,,,percent of total billed charges,,,,,,,,,635.1,,,percent of total billed charges,,,635.1,,,percent of total billed charges,,,620.5,,,percent of total billed charges,,,700.8,,,percent of total billed charges,,,693.5,,,percent of total billed charges,,,,,,,,,657,,,percent of total billed charges,,,,,,,,,678.9,,,percent of total billed charges,,,693.5,,,percent of total billed charges,,,,,,,,,,,,,,,730,,,fee schedule,,,730,,,fee schedule,,,730,,,fee schedule,,,,,,,,,570.13,,,percent of total billed charges,,,664.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS TANDEM UTERI AND OVOID VAG BRACHY,3332756,CDM,361,RC,57155,CPT,,,,,,inpatient,facility,,,1714,719.88,1456.9,1645.44,,1456.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1491.18,,,percent of total billed charges,,,,,,,,,1542.6,,,percent of total billed charges,,,1645.44,,,percent of total billed charges,,,1628.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1594.02,,,percent of total billed charges,,,1628.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INS TANDEM UTERI AND OVOID VAG BRACHY,3332756,CDM,361,RC,57155,CPT,,,,,,outpatient,facility,,,1714,719.88,462.78,5075.58,,1456.9,,,percent of total billed charges,,,462.78,,,percent of total billed charges,,,1179.23,,,percent of total billed charges,,,1153.52,,,percent of total billed charges,,,1448.33,,,percent of total billed charges,,,,,,,,,1491.18,,,percent of total billed charges,,,1491.18,,,percent of total billed charges,,,1456.9,,,percent of total billed charges,,,1645.44,,,percent of total billed charges,,,1628.3,,,percent of total billed charges,,,,,,,,,1542.6,,,percent of total billed charges,,,,,,,,,1594.02,,,percent of total billed charges,,,1628.3,,,percent of total billed charges,,,,,,,,,,,,,,,5075.58,,,fee schedule,,,5075.58,,,fee schedule,,,4974.07,,,fee schedule,,,,,,,,,3522,,,percent of total billed charges,,,1559.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INS TANDEM UTERI AND OVOID VAG BRACHY,3332756,CDM,361,RC,57155,CPT,5415,APC,,,,outpatient,facility,,,1714,1714,2517.81,7359.59,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5075.58,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5177.09,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5075.58,,,fee schedule,,,,,,,,,,,,,,,7359.59,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",6852.03,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5075.58,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5075.58,,,fee schedule,,,5075.58,,,fee schedule,,,2517.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BRACHY STRND P 103 SRCE,3332913,CDM,278,RC,C2640,HCPCS,,,,,,inpatient,facility,,,208,87.36,176.8,199.68,,176.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,180.96,,,percent of total billed charges,,,,,,,,,187.2,,,percent of total billed charges,,,199.68,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,193.44,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRACHY STRND P 103 SRCE,3332913,CDM,278,RC,C2640,HCPCS,,,,,,outpatient,facility,,,208,87.36,56.16,199.68,,176.8,,,percent of total billed charges,,,56.16,,,percent of total billed charges,,,143.1,,,percent of total billed charges,,,139.98,,,percent of total billed charges,,,175.76,,,percent of total billed charges,,,,,,,,,180.96,,,percent of total billed charges,,,180.96,,,percent of total billed charges,,,176.8,,,percent of total billed charges,,,199.68,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,,,,,,,187.2,,,percent of total billed charges,,,,,,,,,193.44,,,percent of total billed charges,,,197.6,,,percent of total billed charges,,,,,,,,,,,,,,,81.6,,,fee schedule,,,81.6,,,fee schedule,,,79.97,,,fee schedule,,,,,,,,,162.45,,,percent of total billed charges,,,189.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRACHY STRND P 103 SRCE,3332913,CDM,278,RC,C2640,HCPCS,2640,APC,,,,outpatient,facility,,,208,208,48.15,110.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,76.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,77.71,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,76.19,,,fee schedule,,,,,,,,,,,,,,,110.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",102.86,,,fee schedule,,,,,,,,,,,,,,,,,,,,,76.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,76.19,,,fee schedule,,,76.19,,,fee schedule,,,48.15,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
DEVICE MLC DESIGN ANDCONST PER IMRT,3333101,CDM,333,RC,77338,CPT,,,,,,inpatient,facility,,,875,367.5,743.75,840,,743.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,761.25,,,percent of total billed charges,,,,,,,,,787.5,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
DEVICE MLC DESIGN ANDCONST PER IMRT,3333101,CDM,333,RC,77338,CPT,,,,,,outpatient,facility,,,875,367.5,236.25,840,,743.75,,,percent of total billed charges,,,236.25,,,percent of total billed charges,,,602,,,percent of total billed charges,,,588.87,,,percent of total billed charges,,,739.38,,,percent of total billed charges,,,,,,,,,761.25,,,percent of total billed charges,,,761.25,,,percent of total billed charges,,,743.75,,,percent of total billed charges,,,840,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,787.5,,,percent of total billed charges,,,,,,,,,813.75,,,percent of total billed charges,,,831.25,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,683.38,,,percent of total billed charges,,,796.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
DEVICE MLC DESIGN ANDCONST PER IMRT,3333101,CDM,333,RC,77338,CPT,5612,APC,,,,outpatient,facility,,,875,875,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
SRS CRANIAL COURSE 1 SESSN,3333135,CDM,333,RC,77372,CPT,,,,,,inpatient,facility,,,20058,8424.36,17049.3,19255.68,,17049.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17450.46,,,percent of total billed charges,,,,,,,,,18052.2,,,percent of total billed charges,,,19255.68,,,percent of total billed charges,,,19055.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,18653.94,,,percent of total billed charges,,,19055.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SRS CRANIAL COURSE 1 SESSN,3333135,CDM,333,RC,77372,CPT,,,,,,outpatient,facility,,,20058,8424.36,5415.66,19255.68,,17049.3,,,percent of total billed charges,,,5415.66,,,percent of total billed charges,,,13799.9,,,percent of total billed charges,,,13499.03,,,percent of total billed charges,,,16949.01,,,percent of total billed charges,,,,,,,,,17450.46,,,percent of total billed charges,,,17450.46,,,percent of total billed charges,,,17049.3,,,percent of total billed charges,,,19255.68,,,percent of total billed charges,,,19055.1,,,percent of total billed charges,,,,,,,,,18052.2,,,percent of total billed charges,,,,,,,,,18653.94,,,percent of total billed charges,,,19055.1,,,percent of total billed charges,,,,,,,,,,,,,,,7946.43,,,fee schedule,,,7946.43,,,fee schedule,,,7787.5,,,fee schedule,,,,,,,,,15665.3,,,percent of total billed charges,,,18252.78,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SRS CRANIAL COURSE 1 SESSN,3333135,CDM,333,RC,77372,CPT,5627,APC,,,,outpatient,facility,,,20058,20058,4177.54,11522.32,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7946.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8105.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,7946.43,,,fee schedule,,,,,,,,,,,,,,,11522.32,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",10727.68,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7946.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,7946.43,,,fee schedule,,,7946.43,,,fee schedule,,,4177.54,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
SRS SBRT LINEAR COURSE MAX 5 SESSNS,3333150,CDM,333,RC,77373,CPT,,,,,,inpatient,facility,,,9721,4082.82,8262.85,9332.16,,8262.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8457.27,,,percent of total billed charges,,,,,,,,,8748.9,,,percent of total billed charges,,,9332.16,,,percent of total billed charges,,,9234.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9040.53,,,percent of total billed charges,,,9234.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SRS SBRT LINEAR COURSE MAX 5 SESSNS,3333150,CDM,333,RC,77373,CPT,,,,,,outpatient,facility,,,9721,4082.82,1784.41,9332.16,,8262.85,,,percent of total billed charges,,,2624.67,,,percent of total billed charges,,,6688.05,,,percent of total billed charges,,,6542.23,,,percent of total billed charges,,,8214.24,,,percent of total billed charges,,,,,,,,,8457.27,,,percent of total billed charges,,,8457.27,,,percent of total billed charges,,,8262.85,,,percent of total billed charges,,,9332.16,,,percent of total billed charges,,,9234.95,,,percent of total billed charges,,,,,,,,,8748.9,,,percent of total billed charges,,,,,,,,,9040.53,,,percent of total billed charges,,,9234.95,,,percent of total billed charges,,,,,,,,,,,,,,,1820.83,,,fee schedule,,,1820.83,,,fee schedule,,,1784.41,,,fee schedule,,,,,,,,,7592.1,,,percent of total billed charges,,,8846.11,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
SRS SBRT LINEAR COURSE MAX 5 SESSNS,3333150,CDM,333,RC,77373,CPT,5626,APC,,,,outpatient,facility,,,9721,9721,960.08,2640.2,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1820.83,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1857.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1820.83,,,fee schedule,,,,,,,,,,,,,,,2640.2,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2458.12,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1820.83,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1820.83,,,fee schedule,,,1820.83,,,fee schedule,,,960.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLAN RADTHRPY 3D W HISTGMS DOSE VOL,3333358,CDM,333,RC,77295,CPT,,,,,,inpatient,facility,,,7200,3024,6120,6912,,6120,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6264,,,percent of total billed charges,,,,,,,,,6480,,,percent of total billed charges,,,6912,,,percent of total billed charges,,,6840,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6696,,,percent of total billed charges,,,6840,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN RADTHRPY 3D W HISTGMS DOSE VOL,3333358,CDM,333,RC,77295,CPT,,,,,,outpatient,facility,,,7200,3024,1385.66,6912,,6120,,,percent of total billed charges,,,1944,,,percent of total billed charges,,,4953.6,,,percent of total billed charges,,,4845.6,,,percent of total billed charges,,,6084,,,percent of total billed charges,,,,,,,,,6264,,,percent of total billed charges,,,6264,,,percent of total billed charges,,,6120,,,percent of total billed charges,,,6912,,,percent of total billed charges,,,6840,,,percent of total billed charges,,,,,,,,,6480,,,percent of total billed charges,,,,,,,,,6696,,,percent of total billed charges,,,6840,,,percent of total billed charges,,,,,,,,,,,,,,,1413.94,,,fee schedule,,,1413.94,,,fee schedule,,,1385.66,,,fee schedule,,,,,,,,,5623.2,,,percent of total billed charges,,,6552,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN RADTHRPY 3D W HISTGMS DOSE VOL,3333358,CDM,333,RC,77295,CPT,5613,APC,,,,outpatient,facility,,,7200,7200,728.26,2050.21,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1413.94,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1442.22,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1413.94,,,fee schedule,,,,,,,,,,,,,,,2050.21,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1908.82,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1413.94,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1413.94,,,fee schedule,,,1413.94,,,fee schedule,,,728.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
SIMULAT MGMT MOTION RESPIRATORY,3333366,CDM,333,RC,77293,CPT,,,,,,inpatient,facility,,,2066,867.72,1756.1,1983.36,,1756.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1797.42,,,percent of total billed charges,,,,,,,,,1859.4,,,percent of total billed charges,,,1983.36,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1921.38,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
SIMULAT MGMT MOTION RESPIRATORY,3333366,CDM,333,RC,77293,CPT,,,,,,outpatient,facility,,,2066,867.72,557.82,2066,,1756.1,,,percent of total billed charges,,,557.82,,,percent of total billed charges,,,1421.41,,,percent of total billed charges,,,1390.42,,,percent of total billed charges,,,1745.77,,,percent of total billed charges,,,,,,,,,1797.42,,,percent of total billed charges,,,1797.42,,,percent of total billed charges,,,1756.1,,,percent of total billed charges,,,1983.36,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,1859.4,,,percent of total billed charges,,,,,,,,,1921.38,,,percent of total billed charges,,,1962.7,,,percent of total billed charges,,,,,,,,,,,,,,,2066,,,fee schedule,,,2066,,,fee schedule,,,2066,,,fee schedule,,,,,,,,,1613.55,,,percent of total billed charges,,,1880.06,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NASOPHARYNGOSCOPY W ENDOSCOPE,3333374,CDM,361,RC,92511,CPT,,,,,,inpatient,facility,,,216,90.72,183.6,207.36,,183.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.92,,,percent of total billed charges,,,,,,,,,194.4,,,percent of total billed charges,,,207.36,,,percent of total billed charges,,,205.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,200.88,,,percent of total billed charges,,,205.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NASOPHARYNGOSCOPY W ENDOSCOPE,3333374,CDM,361,RC,92511,CPT,,,,,,outpatient,facility,,,216,90.72,58.32,207.36,,183.6,,,percent of total billed charges,,,58.32,,,percent of total billed charges,,,148.61,,,percent of total billed charges,,,145.37,,,percent of total billed charges,,,182.52,,,percent of total billed charges,,,,,,,,,187.92,,,percent of total billed charges,,,187.92,,,percent of total billed charges,,,183.6,,,percent of total billed charges,,,207.36,,,percent of total billed charges,,,205.2,,,percent of total billed charges,,,,,,,,,194.4,,,percent of total billed charges,,,,,,,,,200.88,,,percent of total billed charges,,,205.2,,,percent of total billed charges,,,,,,,,,,,,,,,202.13,,,fee schedule,,,202.13,,,fee schedule,,,198.09,,,fee schedule,,,,,,,,,168.7,,,percent of total billed charges,,,196.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NASOPHARYNGOSCOPY W ENDOSCOPE,3333374,CDM,361,RC,92511,CPT,5151,APC,,,,outpatient,facility,,,216,216,97.1,293.09,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,202.13,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,206.17,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,202.13,,,fee schedule,,,,,,,,,,,,,,,293.09,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",272.88,,,fee schedule,,,,,,,,,,,,,,,,,,,,,202.13,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,202.13,,,fee schedule,,,202.13,,,fee schedule,,,97.1,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
GD LOC VOL TARGET DELIVERY TX RAD,3333382,CDM,333,RC,77387,CPT,,,,,,inpatient,facility,,,187,78.54,158.95,179.52,,158.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,162.69,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
GD LOC VOL TARGET DELIVERY TX RAD,3333382,CDM,333,RC,77387,CPT,,,,,,outpatient,facility,,,187,78.54,50.49,187,,158.95,,,percent of total billed charges,,,50.49,,,percent of total billed charges,,,128.66,,,percent of total billed charges,,,125.85,,,percent of total billed charges,,,158.01,,,percent of total billed charges,,,,,,,,,162.69,,,percent of total billed charges,,,162.69,,,percent of total billed charges,,,158.95,,,percent of total billed charges,,,179.52,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,168.3,,,percent of total billed charges,,,,,,,,,173.91,,,percent of total billed charges,,,177.65,,,percent of total billed charges,,,,,,,,,,,,,,,187,,,fee schedule,,,187,,,fee schedule,,,187,,,fee schedule,,,,,,,,,146.05,,,percent of total billed charges,,,170.17,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE TELETHRPY LVL 01 SMPL,3333390,CDM,333,RC,77306,CPT,,,,,,inpatient,facility,,,661,277.62,561.85,634.56,,561.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,575.07,,,percent of total billed charges,,,,,,,,,594.9,,,percent of total billed charges,,,634.56,,,percent of total billed charges,,,627.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,614.73,,,percent of total billed charges,,,627.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE TELETHRPY LVL 01 SMPL,3333390,CDM,333,RC,77306,CPT,,,,,,outpatient,facility,,,661,277.62,178.47,634.56,,561.85,,,percent of total billed charges,,,178.47,,,percent of total billed charges,,,454.77,,,percent of total billed charges,,,444.85,,,percent of total billed charges,,,558.54,,,percent of total billed charges,,,,,,,,,575.07,,,percent of total billed charges,,,575.07,,,percent of total billed charges,,,561.85,,,percent of total billed charges,,,634.56,,,percent of total billed charges,,,627.95,,,percent of total billed charges,,,,,,,,,594.9,,,percent of total billed charges,,,,,,,,,614.73,,,percent of total billed charges,,,627.95,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,516.24,,,percent of total billed charges,,,601.51,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE TELETHRPY LVL 01 SMPL,3333390,CDM,333,RC,77306,CPT,5612,APC,,,,outpatient,facility,,,661,661,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLAN ISODOSE TELETHRPY LVL 02 CMPLX,3333408,CDM,333,RC,77307,CPT,,,,,,inpatient,facility,,,1272,534.24,1081.2,1221.12,,1081.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1106.64,,,percent of total billed charges,,,,,,,,,1144.8,,,percent of total billed charges,,,1221.12,,,percent of total billed charges,,,1208.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1182.96,,,percent of total billed charges,,,1208.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE TELETHRPY LVL 02 CMPLX,3333408,CDM,333,RC,77307,CPT,,,,,,outpatient,facility,,,1272,534.24,343.44,1221.12,,1081.2,,,percent of total billed charges,,,343.44,,,percent of total billed charges,,,875.14,,,percent of total billed charges,,,856.06,,,percent of total billed charges,,,1074.84,,,percent of total billed charges,,,,,,,,,1106.64,,,percent of total billed charges,,,1106.64,,,percent of total billed charges,,,1081.2,,,percent of total billed charges,,,1221.12,,,percent of total billed charges,,,1208.4,,,percent of total billed charges,,,,,,,,,1144.8,,,percent of total billed charges,,,,,,,,,1182.96,,,percent of total billed charges,,,1208.4,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,993.43,,,percent of total billed charges,,,1157.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE TELETHRPY LVL 02 CMPLX,3333408,CDM,333,RC,77307,CPT,5612,APC,,,,outpatient,facility,,,1272,1272,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLAN ISODOSE BRACHY LVL 01 SMPL,3333416,CDM,333,RC,77316,CPT,,,,,,inpatient,facility,,,872,366.24,741.2,837.12,,741.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,758.64,,,percent of total billed charges,,,,,,,,,784.8,,,percent of total billed charges,,,837.12,,,percent of total billed charges,,,828.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,810.96,,,percent of total billed charges,,,828.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE BRACHY LVL 01 SMPL,3333416,CDM,333,RC,77316,CPT,,,,,,outpatient,facility,,,872,366.24,235.44,837.12,,741.2,,,percent of total billed charges,,,235.44,,,percent of total billed charges,,,599.94,,,percent of total billed charges,,,586.86,,,percent of total billed charges,,,736.84,,,percent of total billed charges,,,,,,,,,758.64,,,percent of total billed charges,,,758.64,,,percent of total billed charges,,,741.2,,,percent of total billed charges,,,837.12,,,percent of total billed charges,,,828.4,,,percent of total billed charges,,,,,,,,,784.8,,,percent of total billed charges,,,,,,,,,810.96,,,percent of total billed charges,,,828.4,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,681.03,,,percent of total billed charges,,,793.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE BRACHY LVL 01 SMPL,3333416,CDM,333,RC,77316,CPT,5612,APC,,,,outpatient,facility,,,872,872,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLAN ISODOSE BRACHY LVL 02 INTRM,3333424,CDM,333,RC,77317,CPT,,,,,,inpatient,facility,,,1142,479.64,970.7,1096.32,,970.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,993.54,,,percent of total billed charges,,,,,,,,,1027.8,,,percent of total billed charges,,,1096.32,,,percent of total billed charges,,,1084.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1062.06,,,percent of total billed charges,,,1084.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE BRACHY LVL 02 INTRM,3333424,CDM,333,RC,77317,CPT,,,,,,outpatient,facility,,,1142,479.64,308.34,1096.32,,970.7,,,percent of total billed charges,,,308.34,,,percent of total billed charges,,,785.7,,,percent of total billed charges,,,768.57,,,percent of total billed charges,,,964.99,,,percent of total billed charges,,,,,,,,,993.54,,,percent of total billed charges,,,993.54,,,percent of total billed charges,,,970.7,,,percent of total billed charges,,,1096.32,,,percent of total billed charges,,,1084.9,,,percent of total billed charges,,,,,,,,,1027.8,,,percent of total billed charges,,,,,,,,,1062.06,,,percent of total billed charges,,,1084.9,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,891.9,,,percent of total billed charges,,,1039.22,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE BRACHY LVL 02 INTRM,3333424,CDM,333,RC,77317,CPT,5612,APC,,,,outpatient,facility,,,1142,1142,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
PLAN ISODOSE BRACHY LVL 03 CMPLX,3333432,CDM,333,RC,77318,CPT,,,,,,inpatient,facility,,,1638,687.96,1392.3,1572.48,,1392.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1425.06,,,percent of total billed charges,,,,,,,,,1474.2,,,percent of total billed charges,,,1572.48,,,percent of total billed charges,,,1556.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1523.34,,,percent of total billed charges,,,1556.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE BRACHY LVL 03 CMPLX,3333432,CDM,333,RC,77318,CPT,,,,,,outpatient,facility,,,1638,687.96,369.51,1572.48,,1392.3,,,percent of total billed charges,,,442.26,,,percent of total billed charges,,,1126.94,,,percent of total billed charges,,,1102.37,,,percent of total billed charges,,,1384.11,,,percent of total billed charges,,,,,,,,,1425.06,,,percent of total billed charges,,,1425.06,,,percent of total billed charges,,,1392.3,,,percent of total billed charges,,,1572.48,,,percent of total billed charges,,,1556.1,,,percent of total billed charges,,,,,,,,,1474.2,,,percent of total billed charges,,,,,,,,,1523.34,,,percent of total billed charges,,,1556.1,,,percent of total billed charges,,,,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,369.51,,,fee schedule,,,,,,,,,1279.28,,,percent of total billed charges,,,1490.58,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
PLAN ISODOSE BRACHY LVL 03 CMPLX,3333432,CDM,333,RC,77318,CPT,5612,APC,,,,outpatient,facility,,,1638,1638,194.86,546.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,384.59,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,377.05,,,fee schedule,,,,,,,,,,,,,,,546.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",509.02,,,fee schedule,,,,,,,,,,,,,,,,,,,,,377.05,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,377.05,,,fee schedule,,,377.05,,,fee schedule,,,194.86,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TX RAD 1 AREA  MORE THAN1MEV LVL 01 SMPL,3333457,CDM,333,RC,77402,CPT,,,,,,inpatient,facility,,,562,236.04,477.7,539.52,,477.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,488.94,,,percent of total billed charges,,,,,,,,,505.8,,,percent of total billed charges,,,539.52,,,percent of total billed charges,,,533.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,522.66,,,percent of total billed charges,,,533.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TX RAD 1 AREA  MORE THAN1MEV LVL 01 SMPL,3333457,CDM,333,RC,77402,CPT,,,,,,outpatient,facility,,,562,236.04,119.91,539.52,,477.7,,,percent of total billed charges,,,151.74,,,percent of total billed charges,,,386.66,,,percent of total billed charges,,,378.23,,,percent of total billed charges,,,474.89,,,percent of total billed charges,,,,,,,,,488.94,,,percent of total billed charges,,,488.94,,,percent of total billed charges,,,477.7,,,percent of total billed charges,,,539.52,,,percent of total billed charges,,,533.9,,,percent of total billed charges,,,,,,,,,505.8,,,percent of total billed charges,,,,,,,,,522.66,,,percent of total billed charges,,,533.9,,,percent of total billed charges,,,,,,,,,,,,,,,122.36,,,fee schedule,,,122.36,,,fee schedule,,,119.91,,,fee schedule,,,,,,,,,438.92,,,percent of total billed charges,,,511.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TX RAD 1 AREA  MORE THAN1MEV LVL 01 SMPL,3333457,CDM,333,RC,77402,CPT,5621,APC,,,,outpatient,facility,,,562,562,66.48,177.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,122.36,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,124.81,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,122.36,,,fee schedule,,,,,,,,,,,,,,,177.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",165.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,122.36,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,122.36,,,fee schedule,,,122.36,,,fee schedule,,,66.48,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TX RAD 2 AREAS  MORE THAN1MEV LVL 02 INTRM,3333465,CDM,333,RC,77407,CPT,,,,,,inpatient,facility,,,700,294,595,672,,595,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,609,,,percent of total billed charges,,,,,,,,,630,,,percent of total billed charges,,,672,,,percent of total billed charges,,,665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,651,,,percent of total billed charges,,,665,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TX RAD 2 AREAS  MORE THAN1MEV LVL 02 INTRM,3333465,CDM,333,RC,77407,CPT,,,,,,outpatient,facility,,,700,294,189,672,,595,,,percent of total billed charges,,,189,,,percent of total billed charges,,,481.6,,,percent of total billed charges,,,471.1,,,percent of total billed charges,,,591.5,,,percent of total billed charges,,,,,,,,,609,,,percent of total billed charges,,,609,,,percent of total billed charges,,,595,,,percent of total billed charges,,,672,,,percent of total billed charges,,,665,,,percent of total billed charges,,,,,,,,,630,,,percent of total billed charges,,,,,,,,,651,,,percent of total billed charges,,,665,,,percent of total billed charges,,,,,,,,,,,,,,,274.24,,,fee schedule,,,274.24,,,fee schedule,,,268.76,,,fee schedule,,,,,,,,,546.7,,,percent of total billed charges,,,637,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TX RAD 2 AREAS  MORE THAN1MEV LVL 02 INTRM,3333465,CDM,333,RC,77407,CPT,5622,APC,,,,outpatient,facility,,,700,700,142.83,397.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,274.24,,,fee schedule,,,,,,,,,,,,,,,397.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",370.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,274.24,,,fee schedule,,,274.24,,,fee schedule,,,142.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
TX RAD 3 PLUS AREAS  MORE THAN1MEV LVL 03 CMPLX,3333473,CDM,333,RC,77412,CPT,,,,,,inpatient,facility,,,1047,439.74,889.95,1005.12,,889.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,910.89,,,percent of total billed charges,,,,,,,,,942.3,,,percent of total billed charges,,,1005.12,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,973.71,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
TX RAD 3 PLUS AREAS  MORE THAN1MEV LVL 03 CMPLX,3333473,CDM,333,RC,77412,CPT,,,,,,outpatient,facility,,,1047,439.74,268.76,1005.12,,889.95,,,percent of total billed charges,,,282.69,,,percent of total billed charges,,,720.34,,,percent of total billed charges,,,704.63,,,percent of total billed charges,,,884.71,,,percent of total billed charges,,,,,,,,,910.89,,,percent of total billed charges,,,910.89,,,percent of total billed charges,,,889.95,,,percent of total billed charges,,,1005.12,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,942.3,,,percent of total billed charges,,,,,,,,,973.71,,,percent of total billed charges,,,994.65,,,percent of total billed charges,,,,,,,,,,,,,,,274.24,,,fee schedule,,,274.24,,,fee schedule,,,268.76,,,fee schedule,,,,,,,,,817.71,,,percent of total billed charges,,,952.77,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
TX RAD 3 PLUS AREAS  MORE THAN1MEV LVL 03 CMPLX,3333473,CDM,333,RC,77412,CPT,5622,APC,,,,outpatient,facility,,,1047,1047,142.83,397.65,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,274.24,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,279.72,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,274.24,,,fee schedule,,,,,,,,,,,,,,,397.65,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",370.22,,,fee schedule,,,,,,,,,,,,,,,,,,,,,274.24,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,274.24,,,fee schedule,,,274.24,,,fee schedule,,,142.83,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
IMRT W IMG GD LVL 01 SMPL,3333481,CDM,333,RC,77385,CPT,,,,,,inpatient,facility,,,2277,956.34,1935.45,2185.92,,1935.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1980.99,,,percent of total billed charges,,,,,,,,,2049.3,,,percent of total billed charges,,,2185.92,,,percent of total billed charges,,,2163.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2117.61,,,percent of total billed charges,,,2163.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMRT W IMG GD LVL 01 SMPL,3333481,CDM,333,RC,77385,CPT,,,,,,outpatient,facility,,,2277,956.34,588.68,2185.92,,1935.45,,,percent of total billed charges,,,614.79,,,percent of total billed charges,,,1566.58,,,percent of total billed charges,,,1532.42,,,percent of total billed charges,,,1924.06,,,percent of total billed charges,,,,,,,,,1980.99,,,percent of total billed charges,,,1980.99,,,percent of total billed charges,,,1935.45,,,percent of total billed charges,,,2185.92,,,percent of total billed charges,,,2163.15,,,percent of total billed charges,,,,,,,,,2049.3,,,percent of total billed charges,,,,,,,,,2117.61,,,percent of total billed charges,,,2163.15,,,percent of total billed charges,,,,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,588.68,,,fee schedule,,,,,,,,,1778.34,,,percent of total billed charges,,,2072.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMRT W IMG GD LVL 01 SMPL,3333481,CDM,333,RC,77385,CPT,5623,APC,,,,outpatient,facility,,,2277,2277,310.97,871,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,871,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",810.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,600.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,310.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
IMRT W IMG GD LVL 02 CMPLX,3333499,CDM,333,RC,77386,CPT,,,,,,inpatient,facility,,,2399,1007.58,2039.15,2303.04,,2039.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2087.13,,,percent of total billed charges,,,,,,,,,2159.1,,,percent of total billed charges,,,2303.04,,,percent of total billed charges,,,2279.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2231.07,,,percent of total billed charges,,,2279.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
IMRT W IMG GD LVL 02 CMPLX,3333499,CDM,333,RC,77386,CPT,,,,,,outpatient,facility,,,2399,1007.58,588.68,2303.04,,2039.15,,,percent of total billed charges,,,647.73,,,percent of total billed charges,,,1650.51,,,percent of total billed charges,,,1614.53,,,percent of total billed charges,,,2027.15,,,percent of total billed charges,,,,,,,,,2087.13,,,percent of total billed charges,,,2087.13,,,percent of total billed charges,,,2039.15,,,percent of total billed charges,,,2303.04,,,percent of total billed charges,,,2279.05,,,percent of total billed charges,,,,,,,,,2159.1,,,percent of total billed charges,,,,,,,,,2231.07,,,percent of total billed charges,,,2279.05,,,percent of total billed charges,,,,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,588.68,,,fee schedule,,,,,,,,,1873.62,,,percent of total billed charges,,,2183.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
IMRT W IMG GD LVL 02 CMPLX,3333499,CDM,333,RC,77386,CPT,5623,APC,,,,outpatient,facility,,,2399,2399,310.97,871,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,612.7,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,600.69,,,fee schedule,,,,,,,,,,,,,,,871,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",810.93,,,fee schedule,,,,,,,,,,,,,,,,,,,,,600.69,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,600.69,,,fee schedule,,,600.69,,,fee schedule,,,310.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BRACHY HDR RDNCL ICAV ISTL 1 CH,3333523,CDM,333,RC,77770,CPT,,,,,,inpatient,facility,,,3494,1467.48,2969.9,3354.24,,2969.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3039.78,,,percent of total billed charges,,,,,,,,,3144.6,,,percent of total billed charges,,,3354.24,,,percent of total billed charges,,,3319.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3249.42,,,percent of total billed charges,,,3319.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRACHY HDR RDNCL ICAV ISTL 1 CH,3333523,CDM,333,RC,77770,CPT,,,,,,outpatient,facility,,,3494,1467.48,717,3354.24,,2969.9,,,percent of total billed charges,,,943.38,,,percent of total billed charges,,,2403.87,,,percent of total billed charges,,,2351.46,,,percent of total billed charges,,,2952.43,,,percent of total billed charges,,,,,,,,,3039.78,,,percent of total billed charges,,,3039.78,,,percent of total billed charges,,,2969.9,,,percent of total billed charges,,,3354.24,,,percent of total billed charges,,,3319.3,,,percent of total billed charges,,,,,,,,,3144.6,,,percent of total billed charges,,,,,,,,,3249.42,,,percent of total billed charges,,,3319.3,,,percent of total billed charges,,,,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,717,,,fee schedule,,,,,,,,,2728.81,,,percent of total billed charges,,,3179.54,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRACHY HDR RDNCL ICAV ISTL 1 CH,3333523,CDM,333,RC,77770,CPT,5624,APC,,,,outpatient,facility,,,3494,3494,392.04,1060.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,1060.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",987.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,731.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,392.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BRACHY HDR RDNCL ICAV ISTL 2 12 CH,3333531,CDM,333,RC,77771,CPT,,,,,,inpatient,facility,,,6359,2670.78,5405.15,6104.64,,5405.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5532.33,,,percent of total billed charges,,,,,,,,,5723.1,,,percent of total billed charges,,,6104.64,,,percent of total billed charges,,,6041.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5913.87,,,percent of total billed charges,,,6041.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRACHY HDR RDNCL ICAV ISTL 2 12 CH,3333531,CDM,333,RC,77771,CPT,,,,,,outpatient,facility,,,6359,2670.78,717,6104.64,,5405.15,,,percent of total billed charges,,,1716.93,,,percent of total billed charges,,,4374.99,,,percent of total billed charges,,,4279.61,,,percent of total billed charges,,,5373.35,,,percent of total billed charges,,,,,,,,,5532.33,,,percent of total billed charges,,,5532.33,,,percent of total billed charges,,,5405.15,,,percent of total billed charges,,,6104.64,,,percent of total billed charges,,,6041.05,,,percent of total billed charges,,,,,,,,,5723.1,,,percent of total billed charges,,,,,,,,,5913.87,,,percent of total billed charges,,,6041.05,,,percent of total billed charges,,,,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,717,,,fee schedule,,,,,,,,,4966.38,,,percent of total billed charges,,,5786.69,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRACHY HDR RDNCL ICAV ISTL 2 12 CH,3333531,CDM,333,RC,77771,CPT,5624,APC,,,,outpatient,facility,,,6359,6359,392.04,1060.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,1060.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",987.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,731.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,392.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BRACHY HDR RDNCL ICAV ISTL 13 PLUSCH,3333549,CDM,333,RC,77772,CPT,,,,,,inpatient,facility,,,9643,4050.06,8196.55,9257.28,,8196.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,8389.41,,,percent of total billed charges,,,,,,,,,8678.7,,,percent of total billed charges,,,9257.28,,,percent of total billed charges,,,9160.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,8967.99,,,percent of total billed charges,,,9160.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRACHY HDR RDNCL ICAV ISTL 13 PLUSCH,3333549,CDM,333,RC,77772,CPT,,,,,,outpatient,facility,,,9643,4050.06,717,9257.28,,8196.55,,,percent of total billed charges,,,2603.61,,,percent of total billed charges,,,6634.38,,,percent of total billed charges,,,6489.74,,,percent of total billed charges,,,8148.34,,,percent of total billed charges,,,,,,,,,8389.41,,,percent of total billed charges,,,8389.41,,,percent of total billed charges,,,8196.55,,,percent of total billed charges,,,9257.28,,,percent of total billed charges,,,9160.85,,,percent of total billed charges,,,,,,,,,8678.7,,,percent of total billed charges,,,,,,,,,8967.99,,,percent of total billed charges,,,9160.85,,,percent of total billed charges,,,,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,717,,,fee schedule,,,,,,,,,7531.18,,,percent of total billed charges,,,8775.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRACHY HDR RDNCL ICAV ISTL 13 PLUSCH,3333549,CDM,333,RC,77772,CPT,5624,APC,,,,outpatient,facility,,,9643,9643,392.04,1060.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,746.26,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,731.63,,,fee schedule,,,,,,,,,,,,,,,1060.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",987.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,731.63,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,731.63,,,fee schedule,,,731.63,,,fee schedule,,,392.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM BONE AND JOINT PHASE 3,3411238,CDM,341,RC,78315,CPT,,,,,,inpatient,facility,,,2312,971.04,1965.2,2219.52,,1965.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2011.44,,,percent of total billed charges,,,,,,,,,2080.8,,,percent of total billed charges,,,2219.52,,,percent of total billed charges,,,2196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2150.16,,,percent of total billed charges,,,2196.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT PHASE 3,3411238,CDM,341,RC,78315,CPT,,,,,,outpatient,facility,,,2312,971.04,412.45,2219.52,,1965.2,,,percent of total billed charges,,,624.24,,,percent of total billed charges,,,1590.66,,,percent of total billed charges,,,1555.98,,,percent of total billed charges,,,1953.64,,,percent of total billed charges,,,,,,,,,2011.44,,,percent of total billed charges,,,2011.44,,,percent of total billed charges,,,1965.2,,,percent of total billed charges,,,2219.52,,,percent of total billed charges,,,2196.4,,,percent of total billed charges,,,,,,,,,2080.8,,,percent of total billed charges,,,,,,,,,2150.16,,,percent of total billed charges,,,2196.4,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1805.67,,,percent of total billed charges,,,2103.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT PHASE 3,3411238,CDM,341,RC,78315,CPT,5591,APC,,,,outpatient,facility,,,2312,2312,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM BONE AND JOINT LTD,3411246,CDM,341,RC,78300,CPT,,,,,,inpatient,facility,,,1526,640.92,1297.1,1464.96,,1297.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1327.62,,,percent of total billed charges,,,,,,,,,1373.4,,,percent of total billed charges,,,1464.96,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1419.18,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT LTD,3411246,CDM,341,RC,78300,CPT,,,,,,outpatient,facility,,,1526,640.92,412.02,1464.96,,1297.1,,,percent of total billed charges,,,412.02,,,percent of total billed charges,,,1049.89,,,percent of total billed charges,,,1027,,,percent of total billed charges,,,1289.47,,,percent of total billed charges,,,,,,,,,1327.62,,,percent of total billed charges,,,1327.62,,,percent of total billed charges,,,1297.1,,,percent of total billed charges,,,1464.96,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,1373.4,,,percent of total billed charges,,,,,,,,,1419.18,,,percent of total billed charges,,,1449.7,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1191.81,,,percent of total billed charges,,,1388.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT LTD,3411246,CDM,341,RC,78300,CPT,5591,APC,,,,outpatient,facility,,,1526,1526,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM MARROW BONE LTD,3411253,CDM,341,RC,78102,CPT,,,,,,inpatient,facility,,,819,343.98,696.15,786.24,,696.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,712.53,,,percent of total billed charges,,,,,,,,,737.1,,,percent of total billed charges,,,786.24,,,percent of total billed charges,,,778.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,761.67,,,percent of total billed charges,,,778.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM MARROW BONE LTD,3411253,CDM,341,RC,78102,CPT,,,,,,outpatient,facility,,,819,343.98,221.13,786.24,,696.15,,,percent of total billed charges,,,221.13,,,percent of total billed charges,,,563.47,,,percent of total billed charges,,,551.19,,,percent of total billed charges,,,692.05,,,percent of total billed charges,,,,,,,,,712.53,,,percent of total billed charges,,,712.53,,,percent of total billed charges,,,696.15,,,percent of total billed charges,,,786.24,,,percent of total billed charges,,,778.05,,,percent of total billed charges,,,,,,,,,737.1,,,percent of total billed charges,,,,,,,,,761.67,,,percent of total billed charges,,,778.05,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,639.64,,,percent of total billed charges,,,745.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM MARROW BONE LTD,3411253,CDM,341,RC,78102,CPT,5591,APC,,,,outpatient,facility,,,819,819,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM MARROW BONE MULTIPLE,3411261,CDM,341,RC,78103,CPT,,,,,,inpatient,facility,,,1048,440.16,890.8,1006.08,,890.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,911.76,,,percent of total billed charges,,,,,,,,,943.2,,,percent of total billed charges,,,1006.08,,,percent of total billed charges,,,995.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,974.64,,,percent of total billed charges,,,995.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM MARROW BONE MULTIPLE,3411261,CDM,341,RC,78103,CPT,,,,,,outpatient,facility,,,1048,440.16,282.96,1006.08,,890.8,,,percent of total billed charges,,,282.96,,,percent of total billed charges,,,721.02,,,percent of total billed charges,,,705.3,,,percent of total billed charges,,,885.56,,,percent of total billed charges,,,,,,,,,911.76,,,percent of total billed charges,,,911.76,,,percent of total billed charges,,,890.8,,,percent of total billed charges,,,1006.08,,,percent of total billed charges,,,995.6,,,percent of total billed charges,,,,,,,,,943.2,,,percent of total billed charges,,,,,,,,,974.64,,,percent of total billed charges,,,995.6,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,818.49,,,percent of total billed charges,,,953.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM MARROW BONE MULTIPLE,3411261,CDM,341,RC,78103,CPT,5591,APC,,,,outpatient,facility,,,1048,1048,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM MARROW BONE BODY WHOLE,3411279,CDM,341,RC,78104,CPT,,,,,,inpatient,facility,,,1195,501.9,1015.75,1147.2,,1015.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1039.65,,,percent of total billed charges,,,,,,,,,1075.5,,,percent of total billed charges,,,1147.2,,,percent of total billed charges,,,1135.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1111.35,,,percent of total billed charges,,,1135.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM MARROW BONE BODY WHOLE,3411279,CDM,341,RC,78104,CPT,,,,,,outpatient,facility,,,1195,501.9,322.65,1147.2,,1015.75,,,percent of total billed charges,,,322.65,,,percent of total billed charges,,,822.16,,,percent of total billed charges,,,804.23,,,percent of total billed charges,,,1009.77,,,percent of total billed charges,,,,,,,,,1039.65,,,percent of total billed charges,,,1039.65,,,percent of total billed charges,,,1015.75,,,percent of total billed charges,,,1147.2,,,percent of total billed charges,,,1135.25,,,percent of total billed charges,,,,,,,,,1075.5,,,percent of total billed charges,,,,,,,,,1111.35,,,percent of total billed charges,,,1135.25,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,933.29,,,percent of total billed charges,,,1087.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM MARROW BONE BODY WHOLE,3411279,CDM,341,RC,78104,CPT,5591,APC,,,,outpatient,facility,,,1195,1195,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM BONE AND JOINT MULTIPLE,3411287,CDM,341,RC,78305,CPT,,,,,,inpatient,facility,,,1873,786.66,1592.05,1798.08,,1592.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1629.51,,,percent of total billed charges,,,,,,,,,1685.7,,,percent of total billed charges,,,1798.08,,,percent of total billed charges,,,1779.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1741.89,,,percent of total billed charges,,,1779.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT MULTIPLE,3411287,CDM,341,RC,78305,CPT,,,,,,outpatient,facility,,,1873,786.66,412.45,1798.08,,1592.05,,,percent of total billed charges,,,505.71,,,percent of total billed charges,,,1288.62,,,percent of total billed charges,,,1260.53,,,percent of total billed charges,,,1582.68,,,percent of total billed charges,,,,,,,,,1629.51,,,percent of total billed charges,,,1629.51,,,percent of total billed charges,,,1592.05,,,percent of total billed charges,,,1798.08,,,percent of total billed charges,,,1779.35,,,percent of total billed charges,,,,,,,,,1685.7,,,percent of total billed charges,,,,,,,,,1741.89,,,percent of total billed charges,,,1779.35,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1462.81,,,percent of total billed charges,,,1704.43,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT MULTIPLE,3411287,CDM,341,RC,78305,CPT,5591,APC,,,,outpatient,facility,,,1873,1873,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM BONE AND JOINT BODY WHOLE,3411303,CDM,341,RC,78306,CPT,,,,,,inpatient,facility,,,2012,845.04,1710.2,1931.52,,1710.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1750.44,,,percent of total billed charges,,,,,,,,,1810.8,,,percent of total billed charges,,,1931.52,,,percent of total billed charges,,,1911.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1871.16,,,percent of total billed charges,,,1911.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT BODY WHOLE,3411303,CDM,341,RC,78306,CPT,,,,,,outpatient,facility,,,2012,845.04,412.45,1931.52,,1710.2,,,percent of total billed charges,,,543.24,,,percent of total billed charges,,,1384.26,,,percent of total billed charges,,,1354.08,,,percent of total billed charges,,,1700.14,,,percent of total billed charges,,,,,,,,,1750.44,,,percent of total billed charges,,,1750.44,,,percent of total billed charges,,,1710.2,,,percent of total billed charges,,,1931.52,,,percent of total billed charges,,,1911.4,,,percent of total billed charges,,,,,,,,,1810.8,,,percent of total billed charges,,,,,,,,,1871.16,,,percent of total billed charges,,,1911.4,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1571.37,,,percent of total billed charges,,,1830.92,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BONE AND JOINT BODY WHOLE,3411303,CDM,341,RC,78306,CPT,5591,APC,,,,outpatient,facility,,,2012,2012,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM POOL BLOOD CARDIAC 1ST PASS SGL,3411360,CDM,341,RC,78481,CPT,,,,,,inpatient,facility,,,1735,728.7,1474.75,1665.6,,1474.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1509.45,,,percent of total billed charges,,,,,,,,,1561.5,,,percent of total billed charges,,,1665.6,,,percent of total billed charges,,,1648.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1613.55,,,percent of total billed charges,,,1648.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM POOL BLOOD CARDIAC 1ST PASS SGL,3411360,CDM,341,RC,78481,CPT,,,,,,outpatient,facility,,,1735,728.7,468.45,1665.6,,1474.75,,,percent of total billed charges,,,468.45,,,percent of total billed charges,,,1193.68,,,percent of total billed charges,,,1167.65,,,percent of total billed charges,,,1466.08,,,percent of total billed charges,,,,,,,,,1509.45,,,percent of total billed charges,,,1509.45,,,percent of total billed charges,,,1474.75,,,percent of total billed charges,,,1665.6,,,percent of total billed charges,,,1648.25,,,percent of total billed charges,,,,,,,,,1561.5,,,percent of total billed charges,,,,,,,,,1613.55,,,percent of total billed charges,,,1648.25,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1355.04,,,percent of total billed charges,,,1578.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM POOL BLOOD CARDIAC 1ST PASS SGL,3411360,CDM,341,RC,78481,CPT,5592,APC,,,,outpatient,facility,,,1735,1735,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM DETECTION SHUNT CARDIAC,3411378,CDM,341,RC,78428,CPT,,,,,,inpatient,facility,,,1515,636.3,1287.75,1454.4,,1287.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1318.05,,,percent of total billed charges,,,,,,,,,1363.5,,,percent of total billed charges,,,1454.4,,,percent of total billed charges,,,1439.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1408.95,,,percent of total billed charges,,,1439.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM DETECTION SHUNT CARDIAC,3411378,CDM,341,RC,78428,CPT,,,,,,outpatient,facility,,,1515,636.3,409.05,1454.4,,1287.75,,,percent of total billed charges,,,409.05,,,percent of total billed charges,,,1042.32,,,percent of total billed charges,,,1019.59,,,percent of total billed charges,,,1280.17,,,percent of total billed charges,,,,,,,,,1318.05,,,percent of total billed charges,,,1318.05,,,percent of total billed charges,,,1287.75,,,percent of total billed charges,,,1454.4,,,percent of total billed charges,,,1439.25,,,percent of total billed charges,,,,,,,,,1363.5,,,percent of total billed charges,,,,,,,,,1408.95,,,percent of total billed charges,,,1439.25,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1183.21,,,percent of total billed charges,,,1378.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM DETECTION SHUNT CARDIAC,3411378,CDM,341,RC,78428,CPT,5591,APC,,,,outpatient,facility,,,1515,1515,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM FLOW CSF CISTERNOGRAM,3411394,CDM,341,RC,78630,CPT,,,,,,inpatient,facility,,,1311,550.62,1114.35,1258.56,,1114.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1140.57,,,percent of total billed charges,,,,,,,,,1179.9,,,percent of total billed charges,,,1258.56,,,percent of total billed charges,,,1245.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1219.23,,,percent of total billed charges,,,1245.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM FLOW CSF CISTERNOGRAM,3411394,CDM,341,RC,78630,CPT,,,,,,outpatient,facility,,,1311,550.62,353.97,1258.56,,1114.35,,,percent of total billed charges,,,353.97,,,percent of total billed charges,,,901.97,,,percent of total billed charges,,,882.3,,,percent of total billed charges,,,1107.8,,,percent of total billed charges,,,,,,,,,1140.57,,,percent of total billed charges,,,1140.57,,,percent of total billed charges,,,1114.35,,,percent of total billed charges,,,1258.56,,,percent of total billed charges,,,1245.45,,,percent of total billed charges,,,,,,,,,1179.9,,,percent of total billed charges,,,,,,,,,1219.23,,,percent of total billed charges,,,1245.45,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1023.89,,,percent of total billed charges,,,1193.01,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM FLOW CSF CISTERNOGRAM,3411394,CDM,341,RC,78630,CPT,5592,APC,,,,outpatient,facility,,,1311,1311,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM DETECTION ANDLOC LEAK CSF,3411410,CDM,341,RC,78650,CPT,,,,,,inpatient,facility,,,2143,900.06,1821.55,2057.28,,1821.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1864.41,,,percent of total billed charges,,,,,,,,,1928.7,,,percent of total billed charges,,,2057.28,,,percent of total billed charges,,,2035.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1992.99,,,percent of total billed charges,,,2035.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM DETECTION ANDLOC LEAK CSF,3411410,CDM,341,RC,78650,CPT,,,,,,outpatient,facility,,,2143,900.06,578.61,2057.28,,1821.55,,,percent of total billed charges,,,578.61,,,percent of total billed charges,,,1474.38,,,percent of total billed charges,,,1442.24,,,percent of total billed charges,,,1810.84,,,percent of total billed charges,,,,,,,,,1864.41,,,percent of total billed charges,,,1864.41,,,percent of total billed charges,,,1821.55,,,percent of total billed charges,,,2057.28,,,percent of total billed charges,,,2035.85,,,percent of total billed charges,,,,,,,,,1928.7,,,percent of total billed charges,,,,,,,,,1992.99,,,percent of total billed charges,,,2035.85,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,1673.68,,,percent of total billed charges,,,1950.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM DETECTION ANDLOC LEAK CSF,3411410,CDM,341,RC,78650,CPT,5593,APC,,,,outpatient,facility,,,2143,2143,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM FLOW CSF EVAL SHUNT,3411428,CDM,341,RC,78645,CPT,,,,,,inpatient,facility,,,1225,514.5,1041.25,1176,,1041.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1065.75,,,percent of total billed charges,,,,,,,,,1102.5,,,percent of total billed charges,,,1176,,,percent of total billed charges,,,1163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1139.25,,,percent of total billed charges,,,1163.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM FLOW CSF EVAL SHUNT,3411428,CDM,341,RC,78645,CPT,,,,,,outpatient,facility,,,1225,514.5,330.75,1176,,1041.25,,,percent of total billed charges,,,330.75,,,percent of total billed charges,,,842.8,,,percent of total billed charges,,,824.42,,,percent of total billed charges,,,1035.13,,,percent of total billed charges,,,,,,,,,1065.75,,,percent of total billed charges,,,1065.75,,,percent of total billed charges,,,1041.25,,,percent of total billed charges,,,1176,,,percent of total billed charges,,,1163.75,,,percent of total billed charges,,,,,,,,,1102.5,,,percent of total billed charges,,,,,,,,,1139.25,,,percent of total billed charges,,,1163.75,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,956.73,,,percent of total billed charges,,,1114.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM FLOW CSF EVAL SHUNT,3411428,CDM,341,RC,78645,CPT,5592,APC,,,,outpatient,facility,,,1225,1225,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM REFLEX URETERAL,3411436,CDM,341,RC,78740,CPT,,,,,,inpatient,facility,,,471,197.82,400.35,452.16,,400.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,409.77,,,percent of total billed charges,,,,,,,,,423.9,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM REFLEX URETERAL,3411436,CDM,341,RC,78740,CPT,,,,,,outpatient,facility,,,471,197.82,127.17,452.16,,400.35,,,percent of total billed charges,,,127.17,,,percent of total billed charges,,,324.05,,,percent of total billed charges,,,316.98,,,percent of total billed charges,,,398,,,percent of total billed charges,,,,,,,,,409.77,,,percent of total billed charges,,,409.77,,,percent of total billed charges,,,400.35,,,percent of total billed charges,,,452.16,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,423.9,,,percent of total billed charges,,,,,,,,,438.03,,,percent of total billed charges,,,447.45,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,367.85,,,percent of total billed charges,,,428.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM REFLEX URETERAL,3411436,CDM,341,RC,78740,CPT,5591,APC,,,,outpatient,facility,,,471,471,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM EMPTYING GASTRIC,3411469,CDM,341,RC,78264,CPT,,,,,,inpatient,facility,,,1489,625.38,1265.65,1429.44,,1265.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1295.43,,,percent of total billed charges,,,,,,,,,1340.1,,,percent of total billed charges,,,1429.44,,,percent of total billed charges,,,1414.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1384.77,,,percent of total billed charges,,,1414.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM EMPTYING GASTRIC,3411469,CDM,341,RC,78264,CPT,,,,,,outpatient,facility,,,1489,625.38,402.03,1429.44,,1265.65,,,percent of total billed charges,,,402.03,,,percent of total billed charges,,,1024.43,,,percent of total billed charges,,,1002.1,,,percent of total billed charges,,,1258.2,,,percent of total billed charges,,,,,,,,,1295.43,,,percent of total billed charges,,,1295.43,,,percent of total billed charges,,,1265.65,,,percent of total billed charges,,,1429.44,,,percent of total billed charges,,,1414.55,,,percent of total billed charges,,,,,,,,,1340.1,,,percent of total billed charges,,,,,,,,,1384.77,,,percent of total billed charges,,,1414.55,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1162.91,,,percent of total billed charges,,,1354.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM EMPTYING GASTRIC,3411469,CDM,341,RC,78264,CPT,5591,APC,,,,outpatient,facility,,,1489,1489,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM REFLUX GASTROESOPHAGEAL,3411485,CDM,341,RC,78262,CPT,,,,,,inpatient,facility,,,1405,590.1,1194.25,1348.8,,1194.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1222.35,,,percent of total billed charges,,,,,,,,,1264.5,,,percent of total billed charges,,,1348.8,,,percent of total billed charges,,,1334.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1306.65,,,percent of total billed charges,,,1334.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM REFLUX GASTROESOPHAGEAL,3411485,CDM,341,RC,78262,CPT,,,,,,outpatient,facility,,,1405,590.1,379.35,1348.8,,1194.25,,,percent of total billed charges,,,379.35,,,percent of total billed charges,,,966.64,,,percent of total billed charges,,,945.56,,,percent of total billed charges,,,1187.22,,,percent of total billed charges,,,,,,,,,1222.35,,,percent of total billed charges,,,1222.35,,,percent of total billed charges,,,1194.25,,,percent of total billed charges,,,1348.8,,,percent of total billed charges,,,1334.75,,,percent of total billed charges,,,,,,,,,1264.5,,,percent of total billed charges,,,,,,,,,1306.65,,,percent of total billed charges,,,1334.75,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1097.3,,,percent of total billed charges,,,1278.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM REFLUX GASTROESOPHAGEAL,3411485,CDM,341,RC,78262,CPT,5591,APC,,,,outpatient,facility,,,1405,1405,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOSS BLOOD GI ACUTE,3411493,CDM,341,RC,78278,CPT,,,,,,inpatient,facility,,,1848,776.16,1570.8,1774.08,,1570.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1607.76,,,percent of total billed charges,,,,,,,,,1663.2,,,percent of total billed charges,,,1774.08,,,percent of total billed charges,,,1755.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1718.64,,,percent of total billed charges,,,1755.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOSS BLOOD GI ACUTE,3411493,CDM,341,RC,78278,CPT,,,,,,outpatient,facility,,,1848,776.16,412.45,1774.08,,1570.8,,,percent of total billed charges,,,498.96,,,percent of total billed charges,,,1271.42,,,percent of total billed charges,,,1243.7,,,percent of total billed charges,,,1561.56,,,percent of total billed charges,,,,,,,,,1607.76,,,percent of total billed charges,,,1607.76,,,percent of total billed charges,,,1570.8,,,percent of total billed charges,,,1774.08,,,percent of total billed charges,,,1755.6,,,percent of total billed charges,,,,,,,,,1663.2,,,percent of total billed charges,,,,,,,,,1718.64,,,percent of total billed charges,,,1755.6,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1443.29,,,percent of total billed charges,,,1681.68,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOSS BLOOD GI ACUTE,3411493,CDM,341,RC,78278,CPT,5591,APC,,,,outpatient,facility,,,1848,1848,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LIVER ANDSPLEEN STATIC,3411592,CDM,341,RC,78215,CPT,,,,,,inpatient,facility,,,1328,557.76,1128.8,1274.88,,1128.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1155.36,,,percent of total billed charges,,,,,,,,,1195.2,,,percent of total billed charges,,,1274.88,,,percent of total billed charges,,,1261.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1235.04,,,percent of total billed charges,,,1261.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LIVER ANDSPLEEN STATIC,3411592,CDM,341,RC,78215,CPT,,,,,,outpatient,facility,,,1328,557.76,358.56,1274.88,,1128.8,,,percent of total billed charges,,,358.56,,,percent of total billed charges,,,913.66,,,percent of total billed charges,,,893.74,,,percent of total billed charges,,,1122.16,,,percent of total billed charges,,,,,,,,,1155.36,,,percent of total billed charges,,,1155.36,,,percent of total billed charges,,,1128.8,,,percent of total billed charges,,,1274.88,,,percent of total billed charges,,,1261.6,,,percent of total billed charges,,,,,,,,,1195.2,,,percent of total billed charges,,,,,,,,,1235.04,,,percent of total billed charges,,,1261.6,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1037.17,,,percent of total billed charges,,,1208.48,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LIVER ANDSPLEEN STATIC,3411592,CDM,341,RC,78215,CPT,5591,APC,,,,outpatient,facility,,,1328,1328,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LIVER ANDSPLEEN W FLOW VASCULAR,3411600,CDM,341,RC,78216,CPT,,,,,,inpatient,facility,,,864,362.88,734.4,829.44,,734.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,751.68,,,percent of total billed charges,,,,,,,,,777.6,,,percent of total billed charges,,,829.44,,,percent of total billed charges,,,820.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,803.52,,,percent of total billed charges,,,820.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LIVER ANDSPLEEN W FLOW VASCULAR,3411600,CDM,341,RC,78216,CPT,,,,,,outpatient,facility,,,864,362.88,233.28,829.44,,734.4,,,percent of total billed charges,,,233.28,,,percent of total billed charges,,,594.43,,,percent of total billed charges,,,581.47,,,percent of total billed charges,,,730.08,,,percent of total billed charges,,,,,,,,,751.68,,,percent of total billed charges,,,751.68,,,percent of total billed charges,,,734.4,,,percent of total billed charges,,,829.44,,,percent of total billed charges,,,820.8,,,percent of total billed charges,,,,,,,,,777.6,,,percent of total billed charges,,,,,,,,,803.52,,,percent of total billed charges,,,820.8,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,674.78,,,percent of total billed charges,,,786.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LIVER ANDSPLEEN W FLOW VASCULAR,3411600,CDM,341,RC,78216,CPT,5591,APC,,,,outpatient,facility,,,864,864,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PERF PULMONARY,3411626,CDM,341,RC,78580,CPT,,,,,,inpatient,facility,,,1300,546,1105,1248,,1105,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1131,,,percent of total billed charges,,,,,,,,,1170,,,percent of total billed charges,,,1248,,,percent of total billed charges,,,1235,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1209,,,percent of total billed charges,,,1235,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PERF PULMONARY,3411626,CDM,341,RC,78580,CPT,,,,,,outpatient,facility,,,1300,546,351,1248,,1105,,,percent of total billed charges,,,351,,,percent of total billed charges,,,894.4,,,percent of total billed charges,,,874.9,,,percent of total billed charges,,,1098.5,,,percent of total billed charges,,,,,,,,,1131,,,percent of total billed charges,,,1131,,,percent of total billed charges,,,1105,,,percent of total billed charges,,,1248,,,percent of total billed charges,,,1235,,,percent of total billed charges,,,,,,,,,1170,,,percent of total billed charges,,,,,,,,,1209,,,percent of total billed charges,,,1235,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1015.3,,,percent of total billed charges,,,1183,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PERF PULMONARY,3411626,CDM,341,RC,78580,CPT,5591,APC,,,,outpatient,facility,,,1300,1300,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LYMPH SYSTEM,3411683,CDM,341,RC,78195,CPT,,,,,,inpatient,facility,,,1357,569.94,1153.45,1302.72,,1153.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1180.59,,,percent of total billed charges,,,,,,,,,1221.3,,,percent of total billed charges,,,1302.72,,,percent of total billed charges,,,1289.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1262.01,,,percent of total billed charges,,,1289.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LYMPH SYSTEM,3411683,CDM,341,RC,78195,CPT,,,,,,outpatient,facility,,,1357,569.94,366.39,1302.72,,1153.45,,,percent of total billed charges,,,366.39,,,percent of total billed charges,,,933.62,,,percent of total billed charges,,,913.26,,,percent of total billed charges,,,1146.66,,,percent of total billed charges,,,,,,,,,1180.59,,,percent of total billed charges,,,1180.59,,,percent of total billed charges,,,1153.45,,,percent of total billed charges,,,1302.72,,,percent of total billed charges,,,1289.15,,,percent of total billed charges,,,,,,,,,1221.3,,,percent of total billed charges,,,,,,,,,1262.01,,,percent of total billed charges,,,1289.15,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1059.82,,,percent of total billed charges,,,1234.87,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LYMPH SYSTEM,3411683,CDM,341,RC,78195,CPT,5592,APC,,,,outpatient,facility,,,1357,1357,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM INTESTINE,3411691,CDM,341,RC,78290,CPT,,,,,,inpatient,facility,,,1506,632.52,1280.1,1445.76,,1280.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1310.22,,,percent of total billed charges,,,,,,,,,1355.4,,,percent of total billed charges,,,1445.76,,,percent of total billed charges,,,1430.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1400.58,,,percent of total billed charges,,,1430.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM INTESTINE,3411691,CDM,341,RC,78290,CPT,,,,,,outpatient,facility,,,1506,632.52,406.62,1445.76,,1280.1,,,percent of total billed charges,,,406.62,,,percent of total billed charges,,,1036.13,,,percent of total billed charges,,,1013.54,,,percent of total billed charges,,,1272.57,,,percent of total billed charges,,,,,,,,,1310.22,,,percent of total billed charges,,,1310.22,,,percent of total billed charges,,,1280.1,,,percent of total billed charges,,,1445.76,,,percent of total billed charges,,,1430.7,,,percent of total billed charges,,,,,,,,,1355.4,,,percent of total billed charges,,,,,,,,,1400.58,,,percent of total billed charges,,,1430.7,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1176.19,,,percent of total billed charges,,,1370.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM INTESTINE,3411691,CDM,341,RC,78290,CPT,5591,APC,,,,outpatient,facility,,,1506,1506,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM MUGA REST STRESS PLANAR SGL,3411717,CDM,341,RC,78472,CPT,,,,,,inpatient,facility,,,1892,794.64,1608.2,1816.32,,1608.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1646.04,,,percent of total billed charges,,,,,,,,,1702.8,,,percent of total billed charges,,,1816.32,,,percent of total billed charges,,,1797.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1759.56,,,percent of total billed charges,,,1797.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM MUGA REST STRESS PLANAR SGL,3411717,CDM,341,RC,78472,CPT,,,,,,outpatient,facility,,,1892,794.64,412.45,1816.32,,1608.2,,,percent of total billed charges,,,510.84,,,percent of total billed charges,,,1301.7,,,percent of total billed charges,,,1273.32,,,percent of total billed charges,,,1598.74,,,percent of total billed charges,,,,,,,,,1646.04,,,percent of total billed charges,,,1646.04,,,percent of total billed charges,,,1608.2,,,percent of total billed charges,,,1816.32,,,percent of total billed charges,,,1797.4,,,percent of total billed charges,,,,,,,,,1702.8,,,percent of total billed charges,,,,,,,,,1759.56,,,percent of total billed charges,,,1797.4,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1477.65,,,percent of total billed charges,,,1721.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM MUGA REST STRESS PLANAR SGL,3411717,CDM,341,RC,78472,CPT,5591,APC,,,,outpatient,facility,,,1892,1892,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM MYOCARDIAL INFARCT PLANAR,3411741,CDM,341,RC,78466,CPT,,,,,,inpatient,facility,,,1077,452.34,915.45,1033.92,,915.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,936.99,,,percent of total billed charges,,,,,,,,,969.3,,,percent of total billed charges,,,1033.92,,,percent of total billed charges,,,1023.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1001.61,,,percent of total billed charges,,,1023.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM MYOCARDIAL INFARCT PLANAR,3411741,CDM,341,RC,78466,CPT,,,,,,outpatient,facility,,,1077,452.34,290.79,1033.92,,915.45,,,percent of total billed charges,,,290.79,,,percent of total billed charges,,,740.98,,,percent of total billed charges,,,724.82,,,percent of total billed charges,,,910.06,,,percent of total billed charges,,,,,,,,,936.99,,,percent of total billed charges,,,936.99,,,percent of total billed charges,,,915.45,,,percent of total billed charges,,,1033.92,,,percent of total billed charges,,,1023.15,,,percent of total billed charges,,,,,,,,,969.3,,,percent of total billed charges,,,,,,,,,1001.61,,,percent of total billed charges,,,1023.15,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,841.14,,,percent of total billed charges,,,980.07,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM MYOCARDIAL INFARCT PLANAR,3411741,CDM,341,RC,78466,CPT,5591,APC,,,,outpatient,facility,,,1077,1077,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM KIDNEY FUNCTION ANDFLOW,3411881,CDM,341,RC,78707,CPT,,,,,,inpatient,facility,,,1471,617.82,1250.35,1412.16,,1250.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1279.77,,,percent of total billed charges,,,,,,,,,1323.9,,,percent of total billed charges,,,1412.16,,,percent of total billed charges,,,1397.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1368.03,,,percent of total billed charges,,,1397.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM KIDNEY FUNCTION ANDFLOW,3411881,CDM,341,RC,78707,CPT,,,,,,outpatient,facility,,,1471,617.82,397.17,1412.16,,1250.35,,,percent of total billed charges,,,397.17,,,percent of total billed charges,,,1012.05,,,percent of total billed charges,,,989.98,,,percent of total billed charges,,,1242.99,,,percent of total billed charges,,,,,,,,,1279.77,,,percent of total billed charges,,,1279.77,,,percent of total billed charges,,,1250.35,,,percent of total billed charges,,,1412.16,,,percent of total billed charges,,,1397.45,,,percent of total billed charges,,,,,,,,,1323.9,,,percent of total billed charges,,,,,,,,,1368.03,,,percent of total billed charges,,,1397.45,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1148.85,,,percent of total billed charges,,,1338.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM KIDNEY FUNCTION ANDFLOW,3411881,CDM,341,RC,78707,CPT,5592,APC,,,,outpatient,facility,,,1471,1471,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM KIDNEY FUNCTION ANDFLOW PHARM MULTI,3411899,CDM,341,RC,78709,CPT,,,,,,inpatient,facility,,,2329,978.18,1979.65,2235.84,,1979.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2026.23,,,percent of total billed charges,,,,,,,,,2096.1,,,percent of total billed charges,,,2235.84,,,percent of total billed charges,,,2212.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2165.97,,,percent of total billed charges,,,2212.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM KIDNEY FUNCTION ANDFLOW PHARM MULTI,3411899,CDM,341,RC,78709,CPT,,,,,,outpatient,facility,,,2329,978.18,540.52,2235.84,,1979.65,,,percent of total billed charges,,,628.83,,,percent of total billed charges,,,1602.35,,,percent of total billed charges,,,1567.42,,,percent of total billed charges,,,1968,,,percent of total billed charges,,,,,,,,,2026.23,,,percent of total billed charges,,,2026.23,,,percent of total billed charges,,,1979.65,,,percent of total billed charges,,,2235.84,,,percent of total billed charges,,,2212.55,,,percent of total billed charges,,,,,,,,,2096.1,,,percent of total billed charges,,,,,,,,,2165.97,,,percent of total billed charges,,,2212.55,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1818.95,,,percent of total billed charges,,,2119.39,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM KIDNEY FUNCTION ANDFLOW PHARM MULTI,3411899,CDM,341,RC,78709,CPT,5592,APC,,,,outpatient,facility,,,2329,2329,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM KIDNEY FUNCTION ANDFLOW PHARM SGL,3411907,CDM,341,RC,78708,CPT,,,,,,inpatient,facility,,,1115,468.3,947.75,1070.4,,947.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,970.05,,,percent of total billed charges,,,,,,,,,1003.5,,,percent of total billed charges,,,1070.4,,,percent of total billed charges,,,1059.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1036.95,,,percent of total billed charges,,,1059.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM KIDNEY FUNCTION ANDFLOW PHARM SGL,3411907,CDM,341,RC,78708,CPT,,,,,,outpatient,facility,,,1115,468.3,301.05,1070.4,,947.75,,,percent of total billed charges,,,301.05,,,percent of total billed charges,,,767.12,,,percent of total billed charges,,,750.39,,,percent of total billed charges,,,942.17,,,percent of total billed charges,,,,,,,,,970.05,,,percent of total billed charges,,,970.05,,,percent of total billed charges,,,947.75,,,percent of total billed charges,,,1070.4,,,percent of total billed charges,,,1059.25,,,percent of total billed charges,,,,,,,,,1003.5,,,percent of total billed charges,,,,,,,,,1036.95,,,percent of total billed charges,,,1059.25,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,870.82,,,percent of total billed charges,,,1014.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM KIDNEY FUNCTION ANDFLOW PHARM SGL,3411907,CDM,341,RC,78708,CPT,5592,APC,,,,outpatient,facility,,,1115,1115,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM SPLEEN W WO FLOW VASCULAR,3412004,CDM,341,RC,78185,CPT,,,,,,inpatient,facility,,,678,284.76,576.3,650.88,,576.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,589.86,,,percent of total billed charges,,,,,,,,,610.2,,,percent of total billed charges,,,650.88,,,percent of total billed charges,,,644.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,630.54,,,percent of total billed charges,,,644.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM SPLEEN W WO FLOW VASCULAR,3412004,CDM,341,RC,78185,CPT,,,,,,outpatient,facility,,,678,284.76,183.06,650.88,,576.3,,,percent of total billed charges,,,183.06,,,percent of total billed charges,,,466.46,,,percent of total billed charges,,,456.29,,,percent of total billed charges,,,572.91,,,percent of total billed charges,,,,,,,,,589.86,,,percent of total billed charges,,,589.86,,,percent of total billed charges,,,576.3,,,percent of total billed charges,,,650.88,,,percent of total billed charges,,,644.1,,,percent of total billed charges,,,,,,,,,610.2,,,percent of total billed charges,,,,,,,,,630.54,,,percent of total billed charges,,,644.1,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,529.52,,,percent of total billed charges,,,616.98,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM SPLEEN W WO FLOW VASCULAR,3412004,CDM,341,RC,78185,CPT,5591,APC,,,,outpatient,facility,,,678,678,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM TESTICULAR W FLOW VASCULAR,3412020,CDM,341,RC,78761,CPT,,,,,,inpatient,facility,,,493,207.06,419.05,473.28,,419.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,428.91,,,percent of total billed charges,,,,,,,,,443.7,,,percent of total billed charges,,,473.28,,,percent of total billed charges,,,468.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,458.49,,,percent of total billed charges,,,468.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM TESTICULAR W FLOW VASCULAR,3412020,CDM,341,RC,78761,CPT,,,,,,outpatient,facility,,,493,207.06,133.11,473.28,,419.05,,,percent of total billed charges,,,133.11,,,percent of total billed charges,,,339.18,,,percent of total billed charges,,,331.79,,,percent of total billed charges,,,416.58,,,percent of total billed charges,,,,,,,,,428.91,,,percent of total billed charges,,,428.91,,,percent of total billed charges,,,419.05,,,percent of total billed charges,,,473.28,,,percent of total billed charges,,,468.35,,,percent of total billed charges,,,,,,,,,443.7,,,percent of total billed charges,,,,,,,,,458.49,,,percent of total billed charges,,,468.35,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,385.03,,,percent of total billed charges,,,448.63,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM TESTICULAR W FLOW VASCULAR,3412020,CDM,341,RC,78761,CPT,5591,APC,,,,outpatient,facility,,,493,493,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM METS CA THYROID LTD,3412038,CDM,341,RC,78015,CPT,,,,,,inpatient,facility,,,962,404.04,817.7,923.52,,817.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,836.94,,,percent of total billed charges,,,,,,,,,865.8,,,percent of total billed charges,,,923.52,,,percent of total billed charges,,,913.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,894.66,,,percent of total billed charges,,,913.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM METS CA THYROID LTD,3412038,CDM,341,RC,78015,CPT,,,,,,outpatient,facility,,,962,404.04,259.74,923.52,,817.7,,,percent of total billed charges,,,259.74,,,percent of total billed charges,,,661.86,,,percent of total billed charges,,,647.43,,,percent of total billed charges,,,812.89,,,percent of total billed charges,,,,,,,,,836.94,,,percent of total billed charges,,,836.94,,,percent of total billed charges,,,817.7,,,percent of total billed charges,,,923.52,,,percent of total billed charges,,,913.9,,,percent of total billed charges,,,,,,,,,865.8,,,percent of total billed charges,,,,,,,,,894.66,,,percent of total billed charges,,,913.9,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,751.32,,,percent of total billed charges,,,875.42,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM METS CA THYROID LTD,3412038,CDM,341,RC,78015,CPT,5591,APC,,,,outpatient,facility,,,962,962,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM METS CA THYROID WHOLE BODY,3412053,CDM,341,RC,78018,CPT,,,,,,inpatient,facility,,,1336,561.12,1135.6,1282.56,,1135.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1162.32,,,percent of total billed charges,,,,,,,,,1202.4,,,percent of total billed charges,,,1282.56,,,percent of total billed charges,,,1269.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1242.48,,,percent of total billed charges,,,1269.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM METS CA THYROID WHOLE BODY,3412053,CDM,341,RC,78018,CPT,,,,,,outpatient,facility,,,1336,561.12,360.72,1282.56,,1135.6,,,percent of total billed charges,,,360.72,,,percent of total billed charges,,,919.17,,,percent of total billed charges,,,899.13,,,percent of total billed charges,,,1128.92,,,percent of total billed charges,,,,,,,,,1162.32,,,percent of total billed charges,,,1162.32,,,percent of total billed charges,,,1135.6,,,percent of total billed charges,,,1282.56,,,percent of total billed charges,,,1269.2,,,percent of total billed charges,,,,,,,,,1202.4,,,percent of total billed charges,,,,,,,,,1242.48,,,percent of total billed charges,,,1269.2,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1043.42,,,percent of total billed charges,,,1215.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM METS CA THYROID WHOLE BODY,3412053,CDM,341,RC,78018,CPT,5592,APC,,,,outpatient,facility,,,1336,1336,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOC RRX TMR PLNR WHL BODY 2D IMG,3412160,CDM,341,RC,78804,CPT,,,,,,inpatient,facility,,,2244,942.48,1907.4,2154.24,,1907.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1952.28,,,percent of total billed charges,,,,,,,,,2019.6,,,percent of total billed charges,,,2154.24,,,percent of total billed charges,,,2131.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2086.92,,,percent of total billed charges,,,2131.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR WHL BODY 2D IMG,3412160,CDM,341,RC,78804,CPT,,,,,,outpatient,facility,,,2244,942.48,605.88,2154.24,,1907.4,,,percent of total billed charges,,,605.88,,,percent of total billed charges,,,1543.87,,,percent of total billed charges,,,1510.21,,,percent of total billed charges,,,1896.18,,,percent of total billed charges,,,,,,,,,1952.28,,,percent of total billed charges,,,1952.28,,,percent of total billed charges,,,1907.4,,,percent of total billed charges,,,2154.24,,,percent of total billed charges,,,2131.8,,,percent of total billed charges,,,,,,,,,2019.6,,,percent of total billed charges,,,,,,,,,2086.92,,,percent of total billed charges,,,2131.8,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,1752.56,,,percent of total billed charges,,,2042.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR WHL BODY 2D IMG,3412160,CDM,341,RC,78804,CPT,5593,APC,,,,outpatient,facility,,,2244,2244,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOC RRX TMR PLNR WHL BODY 1D IMG,3412178,CDM,341,RC,78802,CPT,,,,,,inpatient,facility,,,1392,584.64,1183.2,1336.32,,1183.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1211.04,,,percent of total billed charges,,,,,,,,,1252.8,,,percent of total billed charges,,,1336.32,,,percent of total billed charges,,,1322.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1294.56,,,percent of total billed charges,,,1322.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR WHL BODY 1D IMG,3412178,CDM,341,RC,78802,CPT,,,,,,outpatient,facility,,,1392,584.64,375.84,1448.99,,1183.2,,,percent of total billed charges,,,375.84,,,percent of total billed charges,,,957.7,,,percent of total billed charges,,,936.82,,,percent of total billed charges,,,1176.24,,,percent of total billed charges,,,,,,,,,1211.04,,,percent of total billed charges,,,1211.04,,,percent of total billed charges,,,1183.2,,,percent of total billed charges,,,1336.32,,,percent of total billed charges,,,1322.4,,,percent of total billed charges,,,,,,,,,1252.8,,,percent of total billed charges,,,,,,,,,1294.56,,,percent of total billed charges,,,1322.4,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,1087.15,,,percent of total billed charges,,,1266.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR WHL BODY 1D IMG,3412178,CDM,341,RC,78802,CPT,5593,APC,,,,outpatient,facility,,,1392,1392,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM TEST BREATH UREA C14 ACQ,3412186,CDM,341,RC,78267,CPT,,,,,,inpatient,facility,,,598,251.16,508.3,574.08,,508.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,520.26,,,percent of total billed charges,,,,,,,,,538.2,,,percent of total billed charges,,,574.08,,,percent of total billed charges,,,568.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,556.14,,,percent of total billed charges,,,568.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM TEST BREATH UREA C14 ACQ,3412186,CDM,341,RC,78267,CPT,,,,,,outpatient,facility,,,598,251.16,9.62,574.08,,508.3,,,percent of total billed charges,,,161.46,,,percent of total billed charges,,,411.42,,,percent of total billed charges,,,402.45,,,percent of total billed charges,,,505.31,,,percent of total billed charges,,,11.06,,,fee schedule,,,520.26,,,percent of total billed charges,,,520.26,,,percent of total billed charges,,,508.3,,,percent of total billed charges,,,574.08,,,percent of total billed charges,,,568.1,,,percent of total billed charges,,,11.28,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",538.2,,,percent of total billed charges,,,11.06,,,fee schedule,,,556.14,,,percent of total billed charges,,,568.1,,,percent of total billed charges,,,16.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",14.93,,,fee schedule,,,9.82,,,fee schedule,,,9.82,,,fee schedule,,,9.62,,,fee schedule,,,11.06,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",467.04,,,percent of total billed charges,,,544.18,,,percent of total billed charges,,,11.06,,,fee schedule,,,11.06,,,fee schedule,,,,,,,,
NM TEST BREATH UREA C14 ANALYSIS,3412194,CDM,341,RC,78268,CPT,,,,,,inpatient,facility,,,4975,2089.5,4228.75,4776,,4228.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4328.25,,,percent of total billed charges,,,,,,,,,4477.5,,,percent of total billed charges,,,4776,,,percent of total billed charges,,,4726.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4626.75,,,percent of total billed charges,,,4726.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM TEST BREATH UREA C14 ANALYSIS,3412194,CDM,341,RC,78268,CPT,,,,,,outpatient,facility,,,4975,2089.5,82.16,4776,,4228.75,,,percent of total billed charges,,,1343.25,,,percent of total billed charges,,,3422.8,,,percent of total billed charges,,,3348.17,,,percent of total billed charges,,,4203.88,,,percent of total billed charges,,,94.41,,,fee schedule,,,4328.25,,,percent of total billed charges,,,4328.25,,,percent of total billed charges,,,4228.75,,,percent of total billed charges,,,4776,,,percent of total billed charges,,,4726.25,,,percent of total billed charges,,,96.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4477.5,,,percent of total billed charges,,,94.41,,,fee schedule,,,4626.75,,,percent of total billed charges,,,4726.25,,,percent of total billed charges,,,136.89,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",127.45,,,fee schedule,,,83.84,,,fee schedule,,,83.84,,,fee schedule,,,82.16,,,fee schedule,,,94.41,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",3885.47,,,percent of total billed charges,,,4527.25,,,percent of total billed charges,,,94.41,,,fee schedule,,,94.41,,,fee schedule,,,,,,,,
THERAPY RRX PO HYPTHYROID INIT,3412244,CDM,342,RC,79005,CPT,,,,,,inpatient,facility,,,2034,854.28,1728.9,1952.64,,1728.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1769.58,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO HYPTHYROID INIT,3412244,CDM,342,RC,79005,CPT,,,,,,outpatient,facility,,,2034,854.28,248.79,1952.64,,1728.9,,,percent of total billed charges,,,549.18,,,percent of total billed charges,,,1399.39,,,percent of total billed charges,,,1368.88,,,percent of total billed charges,,,1718.73,,,percent of total billed charges,,,,,,,,,1769.58,,,percent of total billed charges,,,1769.58,,,percent of total billed charges,,,1728.9,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,248.79,,,fee schedule,,,,,,,,,1588.55,,,percent of total billed charges,,,1850.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO HYPTHYROID INIT,3412244,CDM,342,RC,79005,CPT,5661,APC,,,,outpatient,facility,,,2034,2034,135.65,368.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,368.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",342.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,253.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,135.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THERAPY RRX PO HYPTHYROID ADDL,3412251,CDM,342,RC,79005,CPT,,,,,,inpatient,facility,,,2034,854.28,1728.9,1952.64,,1728.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1769.58,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO HYPTHYROID ADDL,3412251,CDM,342,RC,79005,CPT,,,,,,outpatient,facility,,,2034,854.28,248.79,1952.64,,1728.9,,,percent of total billed charges,,,549.18,,,percent of total billed charges,,,1399.39,,,percent of total billed charges,,,1368.88,,,percent of total billed charges,,,1718.73,,,percent of total billed charges,,,,,,,,,1769.58,,,percent of total billed charges,,,1769.58,,,percent of total billed charges,,,1728.9,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,248.79,,,fee schedule,,,,,,,,,1588.55,,,percent of total billed charges,,,1850.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO HYPTHYROID ADDL,3412251,CDM,342,RC,79005,CPT,5661,APC,,,,outpatient,facility,,,2034,2034,135.65,368.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,368.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",342.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,253.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,135.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THERAPY RRX INTRAARTICULAR,3412269,CDM,342,RC,79440,CPT,,,,,,inpatient,facility,,,436,183.12,370.6,418.56,,370.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,379.32,,,percent of total billed charges,,,,,,,,,392.4,,,percent of total billed charges,,,418.56,,,percent of total billed charges,,,414.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,405.48,,,percent of total billed charges,,,414.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY RRX INTRAARTICULAR,3412269,CDM,342,RC,79440,CPT,,,,,,outpatient,facility,,,436,183.12,117.72,418.56,,370.6,,,percent of total billed charges,,,117.72,,,percent of total billed charges,,,299.97,,,percent of total billed charges,,,293.43,,,percent of total billed charges,,,368.42,,,percent of total billed charges,,,,,,,,,379.32,,,percent of total billed charges,,,379.32,,,percent of total billed charges,,,370.6,,,percent of total billed charges,,,418.56,,,percent of total billed charges,,,414.2,,,percent of total billed charges,,,,,,,,,392.4,,,percent of total billed charges,,,,,,,,,405.48,,,percent of total billed charges,,,414.2,,,percent of total billed charges,,,,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,248.79,,,fee schedule,,,,,,,,,340.52,,,percent of total billed charges,,,396.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX INTRAARTICULAR,3412269,CDM,342,RC,79440,CPT,5661,APC,,,,outpatient,facility,,,436,436,135.65,368.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,368.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",342.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,253.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,135.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THERAPY RRX PO THYROID CA ABL,3412301,CDM,342,RC,79005,CPT,,,,,,inpatient,facility,,,2034,854.28,1728.9,1952.64,,1728.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1769.58,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO THYROID CA ABL,3412301,CDM,342,RC,79005,CPT,,,,,,outpatient,facility,,,2034,854.28,248.79,1952.64,,1728.9,,,percent of total billed charges,,,549.18,,,percent of total billed charges,,,1399.39,,,percent of total billed charges,,,1368.88,,,percent of total billed charges,,,1718.73,,,percent of total billed charges,,,,,,,,,1769.58,,,percent of total billed charges,,,1769.58,,,percent of total billed charges,,,1728.9,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,248.79,,,fee schedule,,,,,,,,,1588.55,,,percent of total billed charges,,,1850.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO THYROID CA ABL,3412301,CDM,342,RC,79005,CPT,5661,APC,,,,outpatient,facility,,,2034,2034,135.65,368.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,368.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",342.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,253.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,135.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THERAPY RRX PO THYROID CA METS,3412319,CDM,342,RC,79005,CPT,,,,,,inpatient,facility,,,2034,854.28,1728.9,1952.64,,1728.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1769.58,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO THYROID CA METS,3412319,CDM,342,RC,79005,CPT,,,,,,outpatient,facility,,,2034,854.28,248.79,1952.64,,1728.9,,,percent of total billed charges,,,549.18,,,percent of total billed charges,,,1399.39,,,percent of total billed charges,,,1368.88,,,percent of total billed charges,,,1718.73,,,percent of total billed charges,,,,,,,,,1769.58,,,percent of total billed charges,,,1769.58,,,percent of total billed charges,,,1728.9,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,248.79,,,fee schedule,,,,,,,,,1588.55,,,percent of total billed charges,,,1850.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO THYROID CA METS,3412319,CDM,342,RC,79005,CPT,5661,APC,,,,outpatient,facility,,,2034,2034,135.65,368.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,368.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",342.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,253.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,135.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
THERAPY RRX PO THYROID SUPPRESSION,3412327,CDM,342,RC,79005,CPT,,,,,,inpatient,facility,,,2034,854.28,1728.9,1952.64,,1728.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1769.58,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO THYROID SUPPRESSION,3412327,CDM,342,RC,79005,CPT,,,,,,outpatient,facility,,,2034,854.28,248.79,1952.64,,1728.9,,,percent of total billed charges,,,549.18,,,percent of total billed charges,,,1399.39,,,percent of total billed charges,,,1368.88,,,percent of total billed charges,,,1718.73,,,percent of total billed charges,,,,,,,,,1769.58,,,percent of total billed charges,,,1769.58,,,percent of total billed charges,,,1728.9,,,percent of total billed charges,,,1952.64,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,1830.6,,,percent of total billed charges,,,,,,,,,1891.62,,,percent of total billed charges,,,1932.3,,,percent of total billed charges,,,,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,248.79,,,fee schedule,,,,,,,,,1588.55,,,percent of total billed charges,,,1850.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX PO THYROID SUPPRESSION,3412327,CDM,342,RC,79005,CPT,5661,APC,,,,outpatient,facility,,,2034,2034,135.65,368.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,368.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",342.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,253.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,135.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RRX DISOFENIN DX 0 15MCI DOSE,3412343,CDM,343,RC,A9510,HCPCS,,,,,,inpatient,facility,,,253,106.26,215.05,242.88,,215.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,220.11,,,percent of total billed charges,,,,,,,,,227.7,,,percent of total billed charges,,,242.88,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,235.29,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX DISOFENIN DX 0 15MCI DOSE,3412343,CDM,343,RC,A9510,HCPCS,,,,,,outpatient,facility,,,253,106.26,68.31,253,,215.05,,,percent of total billed charges,,,68.31,,,percent of total billed charges,,,174.06,,,percent of total billed charges,,,170.27,,,percent of total billed charges,,,213.78,,,percent of total billed charges,,,,,,,,,220.11,,,percent of total billed charges,,,220.11,,,percent of total billed charges,,,215.05,,,percent of total billed charges,,,242.88,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,227.7,,,percent of total billed charges,,,,,,,,,235.29,,,percent of total billed charges,,,240.35,,,percent of total billed charges,,,,,,,,,,,,,,,253,,,fee schedule,,,253,,,fee schedule,,,253,,,fee schedule,,,,,,,,,151.77,,,percent of total billed charges,,Paid in addition to outpatient services ,230.23,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX I 123 IOBENG DX 0 15MCI DOSE,3412400,CDM,343,RC,A9582,HCPCS,,,,,,inpatient,facility,,,6208,2607.36,5276.8,5959.68,,5276.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5400.96,,,percent of total billed charges,,,,,,,,,5587.2,,,percent of total billed charges,,,5959.68,,,percent of total billed charges,,,5897.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5773.44,,,percent of total billed charges,,,5897.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX I 123 IOBENG DX 0 15MCI DOSE,3412400,CDM,343,RC,A9582,HCPCS,,,,,,outpatient,facility,,,6208,2607.36,1676.16,6208,,5276.8,,,percent of total billed charges,,,1676.16,,,percent of total billed charges,,,4271.1,,,percent of total billed charges,,,4177.98,,,percent of total billed charges,,,5245.76,,,percent of total billed charges,,,,,,,,,5400.96,,,percent of total billed charges,,,5400.96,,,percent of total billed charges,,,5276.8,,,percent of total billed charges,,,5959.68,,,percent of total billed charges,,,5897.6,,,percent of total billed charges,,,,,,,,,5587.2,,,percent of total billed charges,,,,,,,,,5773.44,,,percent of total billed charges,,,5897.6,,,percent of total billed charges,,,,,,,,,,,,,,,6208,,,fee schedule,,,6208,,,fee schedule,,,6208,,,fee schedule,,,,,,,,,4795.79,,,percent of total billed charges,,Paid in addition to outpatient services ,5649.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX MEDRONATE DX 0 30MCI DOSE,3412434,CDM,343,RC,A9503,HCPCS,,,,,,inpatient,facility,,,168,70.56,142.8,161.28,,142.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,146.16,,,percent of total billed charges,,,,,,,,,151.2,,,percent of total billed charges,,,161.28,,,percent of total billed charges,,,159.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,156.24,,,percent of total billed charges,,,159.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX MEDRONATE DX 0 30MCI DOSE,3412434,CDM,343,RC,A9503,HCPCS,,,,,,outpatient,facility,,,168,70.56,45.36,168,,142.8,,,percent of total billed charges,,,45.36,,,percent of total billed charges,,,115.58,,,percent of total billed charges,,,113.06,,,percent of total billed charges,,,141.96,,,percent of total billed charges,,,,,,,,,146.16,,,percent of total billed charges,,,146.16,,,percent of total billed charges,,,142.8,,,percent of total billed charges,,,161.28,,,percent of total billed charges,,,159.6,,,percent of total billed charges,,,,,,,,,151.2,,,percent of total billed charges,,,,,,,,,156.24,,,percent of total billed charges,,,159.6,,,percent of total billed charges,,,,,,,,,,,,,,,168,,,fee schedule,,,168,,,fee schedule,,,168,,,fee schedule,,,,,,,,,81.61,,,percent of total billed charges,,Paid in addition to outpatient services ,152.88,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX GALLIUM 67 DX MCI,3412558,CDM,343,RC,A9556,HCPCS,,,,,,inpatient,facility,,,455,191.1,386.75,436.8,,386.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,395.85,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,436.8,,,percent of total billed charges,,,432.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,423.15,,,percent of total billed charges,,,432.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX GALLIUM 67 DX MCI,3412558,CDM,343,RC,A9556,HCPCS,,,,,,outpatient,facility,,,455,191.1,48.68,455,,386.75,,,percent of total billed charges,,,122.85,,,percent of total billed charges,,,313.04,,,percent of total billed charges,,,306.21,,,percent of total billed charges,,,384.47,,,percent of total billed charges,,,,,,,,,395.85,,,percent of total billed charges,,,395.85,,,percent of total billed charges,,,386.75,,,percent of total billed charges,,,436.8,,,percent of total billed charges,,,432.25,,,percent of total billed charges,,,,,,,,,409.5,,,percent of total billed charges,,,,,,,,,423.15,,,percent of total billed charges,,,432.25,,,percent of total billed charges,,,,,,,,,,,,,,,455,,,fee schedule,,,455,,,fee schedule,,,455,,,fee schedule,,,,,,,,,48.68,,,percent of total billed charges,,Paid in addition to outpatient services ,414.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 PENTETATE DX 0.5MCI,3412608,CDM,343,RC,A9548,HCPCS,,,,,,inpatient,facility,,,1865,783.3,1585.25,1790.4,,1585.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1622.55,,,percent of total billed charges,,,,,,,,,1678.5,,,percent of total billed charges,,,1790.4,,,percent of total billed charges,,,1771.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1734.45,,,percent of total billed charges,,,1771.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 PENTETATE DX 0.5MCI,3412608,CDM,343,RC,A9548,HCPCS,,,,,,outpatient,facility,,,1865,783.3,392.31,1865,,1585.25,,,percent of total billed charges,,,503.55,,,percent of total billed charges,,,1283.12,,,percent of total billed charges,,,1255.14,,,percent of total billed charges,,,1575.92,,,percent of total billed charges,,,,,,,,,1622.55,,,percent of total billed charges,,,1622.55,,,percent of total billed charges,,,1585.25,,,percent of total billed charges,,,1790.4,,,percent of total billed charges,,,1771.75,,,percent of total billed charges,,,,,,,,,1678.5,,,percent of total billed charges,,,,,,,,,1734.45,,,percent of total billed charges,,,1771.75,,,percent of total billed charges,,,,,,,,,,,,,,,1865,,,fee schedule,,,1865,,,fee schedule,,,1865,,,fee schedule,,,,,,,,,392.31,,,percent of total billed charges,,Paid in addition to outpatient services ,1697.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 OXYQ DX 0.5MCI,3412624,CDM,343,RC,A9547,HCPCS,,,,,,inpatient,facility,,,1749,734.58,1486.65,1679.04,,1486.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1521.63,,,percent of total billed charges,,,,,,,,,1574.1,,,percent of total billed charges,,,1679.04,,,percent of total billed charges,,,1661.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1626.57,,,percent of total billed charges,,,1661.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 OXYQ DX 0.5MCI,3412624,CDM,343,RC,A9547,HCPCS,,,,,,outpatient,facility,,,1749,734.58,472.23,1749,,1486.65,,,percent of total billed charges,,,472.23,,,percent of total billed charges,,,1203.31,,,percent of total billed charges,,,1177.08,,,percent of total billed charges,,,1477.9,,,percent of total billed charges,,,,,,,,,1521.63,,,percent of total billed charges,,,1521.63,,,percent of total billed charges,,,1486.65,,,percent of total billed charges,,,1679.04,,,percent of total billed charges,,,1661.55,,,percent of total billed charges,,,,,,,,,1574.1,,,percent of total billed charges,,,,,,,,,1626.57,,,percent of total billed charges,,,1661.55,,,percent of total billed charges,,,,,,,,,,,,,,,1749,,,fee schedule,,,1749,,,fee schedule,,,1749,,,fee schedule,,,,,,,,,654.33,,,percent of total billed charges,,Paid in addition to outpatient services ,1591.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX TETROFOSMIN DX DOSE,3412657,CDM,343,RC,A9502,HCPCS,,,,,,inpatient,facility,,,275,115.5,233.75,264,,233.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,239.25,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX TETROFOSMIN DX DOSE,3412657,CDM,343,RC,A9502,HCPCS,,,,,,outpatient,facility,,,275,115.5,74.25,320.72,,233.75,,,percent of total billed charges,,,74.25,,,percent of total billed charges,,,189.2,,,percent of total billed charges,,,185.07,,,percent of total billed charges,,,232.38,,,percent of total billed charges,,,,,,,,,239.25,,,percent of total billed charges,,,239.25,,,percent of total billed charges,,,233.75,,,percent of total billed charges,,,264,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,247.5,,,percent of total billed charges,,,,,,,,,255.75,,,percent of total billed charges,,,261.25,,,percent of total billed charges,,,,,,,,,,,,,,,275,,,fee schedule,,,275,,,fee schedule,,,275,,,fee schedule,,,,,,,,,320.72,,,percent of total billed charges,,Paid in addition to outpatient services ,250.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX CHROM PHOS 32 THR MCI,3412673,CDM,344,RC,A9564,HCPCS,,,,,,inpatient,facility,,,623,261.66,529.55,598.08,,529.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,542.01,,,percent of total billed charges,,,,,,,,,560.7,,,percent of total billed charges,,,598.08,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,579.39,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX CHROM PHOS 32 THR MCI,3412673,CDM,344,RC,A9564,HCPCS,,,,,,outpatient,facility,,,623,261.66,168.21,623,,529.55,,,percent of total billed charges,,,168.21,,,percent of total billed charges,,,428.62,,,percent of total billed charges,,,419.28,,,percent of total billed charges,,,526.43,,,percent of total billed charges,,,,,,,,,542.01,,,percent of total billed charges,,,542.01,,,percent of total billed charges,,,529.55,,,percent of total billed charges,,,598.08,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,,,,,,,560.7,,,percent of total billed charges,,,,,,,,,579.39,,,percent of total billed charges,,,591.85,,,percent of total billed charges,,,373.8,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,623,,,fee schedule,,,623,,,fee schedule,,,623,,,fee schedule,,,623,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",335.03,,,percent of total billed charges,,Paid in addition to outpatient services ,566.93,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX SESTAMIBI DX DOSE,3412707,CDM,343,RC,A9500,HCPCS,,,,,,inpatient,facility,,,219,91.98,186.15,210.24,,186.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,190.53,,,percent of total billed charges,,,,,,,,,197.1,,,percent of total billed charges,,,210.24,,,percent of total billed charges,,,208.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,203.67,,,percent of total billed charges,,,208.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX SESTAMIBI DX DOSE,3412707,CDM,343,RC,A9500,HCPCS,,,,,,outpatient,facility,,,219,91.98,59.13,968.75,,186.15,,,percent of total billed charges,,,59.13,,,percent of total billed charges,,,150.67,,,percent of total billed charges,,,147.39,,,percent of total billed charges,,,185.06,,,percent of total billed charges,,,,,,,,,190.53,,,percent of total billed charges,,,190.53,,,percent of total billed charges,,,186.15,,,percent of total billed charges,,,210.24,,,percent of total billed charges,,,208.05,,,percent of total billed charges,,,,,,,,,197.1,,,percent of total billed charges,,,,,,,,,203.67,,,percent of total billed charges,,,208.05,,,percent of total billed charges,,,,,,,,,,,,,,,219,,,fee schedule,,,219,,,fee schedule,,,219,,,fee schedule,,,,,,,,,968.75,,,percent of total billed charges,,Paid in addition to outpatient services ,199.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX THALLIUM CL 201 DX MCI,3412723,CDM,343,RC,A9505,HCPCS,,,,,,inpatient,facility,,,550,231,467.5,528,,467.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,478.5,,,percent of total billed charges,,,,,,,,,495,,,percent of total billed charges,,,528,,,percent of total billed charges,,,522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,511.5,,,percent of total billed charges,,,522.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX THALLIUM CL 201 DX MCI,3412723,CDM,343,RC,A9505,HCPCS,,,,,,outpatient,facility,,,550,231,148.5,550,,467.5,,,percent of total billed charges,,,148.5,,,percent of total billed charges,,,378.4,,,percent of total billed charges,,,370.15,,,percent of total billed charges,,,464.75,,,percent of total billed charges,,,,,,,,,478.5,,,percent of total billed charges,,,478.5,,,percent of total billed charges,,,467.5,,,percent of total billed charges,,,528,,,percent of total billed charges,,,522.5,,,percent of total billed charges,,,,,,,,,495,,,percent of total billed charges,,,,,,,,,511.5,,,percent of total billed charges,,,522.5,,,percent of total billed charges,,,,,,,,,,,,,,,550,,,fee schedule,,,550,,,fee schedule,,,550,,,fee schedule,,,,,,,,,175.4,,,percent of total billed charges,,Paid in addition to outpatient services ,500.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRACHY N STRND YTTR 90 SIRSP SRCE,3412731,CDM,278,RC,C2616,HCPCS,,,,,,inpatient,facility,,,75774,31825.08,64407.9,72743.04,,64407.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,65923.38,,,percent of total billed charges,,,,,,,,,68196.6,,,percent of total billed charges,,,72743.04,,,percent of total billed charges,,,71985.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,70469.82,,,percent of total billed charges,,,71985.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BRACHY N STRND YTTR 90 SIRSP SRCE,3412731,CDM,278,RC,C2616,HCPCS,,,,,,outpatient,facility,,,75774,31825.08,18028.65,72743.04,,64407.9,,,percent of total billed charges,,,20458.98,,,percent of total billed charges,,,52132.51,,,percent of total billed charges,,,50995.9,,,percent of total billed charges,,,64029.03,,,percent of total billed charges,,,,,,,,,65923.38,,,percent of total billed charges,,,65923.38,,,percent of total billed charges,,,64407.9,,,percent of total billed charges,,,72743.04,,,percent of total billed charges,,,71985.3,,,percent of total billed charges,,,,,,,,,68196.6,,,percent of total billed charges,,,,,,,,,70469.82,,,percent of total billed charges,,,71985.3,,,percent of total billed charges,,,,,,,,,,,,,,,18396.58,,,fee schedule,,,18396.58,,,fee schedule,,,18028.65,,,fee schedule,,,,,,,,,59179.49,,,percent of total billed charges,,Paid in addition to outpatient services ,68954.34,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BRACHY N STRND YTTR 90 SIRSP SRCE,3412731,CDM,278,RC,C2616,HCPCS,2616,APC,,,,outpatient,facility,,,75774,75774,9565.67,24906.66,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17177.01,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,17520.55,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,17177.01,,,fee schedule,,,,,,,,,,,,,,,24906.66,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",23188.96,,,fee schedule,,,,,,,,,,,,,,,,,,,,,17177.01,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,17177.01,,,fee schedule,,,17177.01,,,fee schedule,,,9565.67,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RRX I 131 IOD NA DX MCI CAP,3412780,CDM,343,RC,A9528,HCPCS,,,,,,inpatient,facility,,,85,35.7,72.25,81.6,,72.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,73.95,,,percent of total billed charges,,,,,,,,,76.5,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX I 131 IOD NA DX MCI CAP,3412780,CDM,343,RC,A9528,HCPCS,,,,,,outpatient,facility,,,85,35.7,22.95,209.04,,72.25,,,percent of total billed charges,,,22.95,,,percent of total billed charges,,,58.48,,,percent of total billed charges,,,57.2,,,percent of total billed charges,,,71.83,,,percent of total billed charges,,,,,,,,,73.95,,,percent of total billed charges,,,73.95,,,percent of total billed charges,,,72.25,,,percent of total billed charges,,,81.6,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,76.5,,,percent of total billed charges,,,,,,,,,79.05,,,percent of total billed charges,,,80.75,,,percent of total billed charges,,,,,,,,,,,,,,,85,,,fee schedule,,,85,,,fee schedule,,,85,,,fee schedule,,,,,,,,,209.04,,,percent of total billed charges,,Paid in addition to outpatient services ,77.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX I 131 IOD NA THPY MCI CAP,3412798,CDM,344,RC,A9517,HCPCS,,,,,,inpatient,facility,,,160,67.2,136,153.6,,136,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,139.2,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX I 131 IOD NA THPY MCI CAP,3412798,CDM,344,RC,A9517,HCPCS,,,,,,outpatient,facility,,,160,67.2,43.2,160,,136,,,percent of total billed charges,,,43.2,,,percent of total billed charges,,,110.08,,,percent of total billed charges,,,107.68,,,percent of total billed charges,,,135.2,,,percent of total billed charges,,,,,,,,,139.2,,,percent of total billed charges,,,139.2,,,percent of total billed charges,,,136,,,percent of total billed charges,,,153.6,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,144,,,percent of total billed charges,,,,,,,,,148.8,,,percent of total billed charges,,,152,,,percent of total billed charges,,,,,,,,,,,,,,,160,,,fee schedule,,,160,,,fee schedule,,,160,,,fee schedule,,,,,,,,,45.88,,,percent of total billed charges,,Paid in addition to outpatient services ,145.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX I 131 IOD NA THPY MCI CAP,3412798,CDM,344,RC,A9517,HCPCS,1064,APC,,,,outpatient,facility,,,160,160,21.34,28.81,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,28.81,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,21.34,,,fee schedule,,,21.34,,,fee schedule,,,,,,,,
RRX PERTECHNETATE DX MCI,3412814,CDM,343,RC,A9512,HCPCS,,,,,,inpatient,facility,,,13,5.46,11.05,12.48,,11.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11.31,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX PERTECHNETATE DX MCI,3412814,CDM,343,RC,A9512,HCPCS,,,,,,outpatient,facility,,,13,5.46,3.51,13.61,,11.05,,,percent of total billed charges,,,3.51,,,percent of total billed charges,,,8.94,,,percent of total billed charges,,,8.75,,,percent of total billed charges,,,10.98,,,percent of total billed charges,,,,,,,,,11.31,,,percent of total billed charges,,,11.31,,,percent of total billed charges,,,11.05,,,percent of total billed charges,,,12.48,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,11.7,,,percent of total billed charges,,,,,,,,,12.09,,,percent of total billed charges,,,12.35,,,percent of total billed charges,,,,,,,,,,,,,,,13,,,fee schedule,,,13,,,fee schedule,,,13,,,fee schedule,,,,,,,,,13.61,,,percent of total billed charges,,Paid in addition to outpatient services ,11.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX STRONTIUM 89 THR MCI,3412855,CDM,344,RC,A9600,HCPCS,,,,,,inpatient,facility,,,7598,3191.16,6458.3,7294.08,,6458.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6610.26,,,percent of total billed charges,,,,,,,,,6838.2,,,percent of total billed charges,,,7294.08,,,percent of total billed charges,,,7218.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,7066.14,,,percent of total billed charges,,,7218.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX STRONTIUM 89 THR MCI,3412855,CDM,344,RC,A9600,HCPCS,,,,,,outpatient,facility,,,7598,3191.16,2051.46,8936.63,,6458.3,,,percent of total billed charges,,,2051.46,,,percent of total billed charges,,,5227.42,,,percent of total billed charges,,,5113.45,,,percent of total billed charges,,,6420.31,,,percent of total billed charges,,,,,,,,,6610.26,,,percent of total billed charges,,,6610.26,,,percent of total billed charges,,,6458.3,,,percent of total billed charges,,,7294.08,,,percent of total billed charges,,,7218.1,,,percent of total billed charges,,,,,,,,,6838.2,,,percent of total billed charges,,,,,,,,,7066.14,,,percent of total billed charges,,,7218.1,,,percent of total billed charges,,,,,,,,,,,,,,,7598,,,fee schedule,,,7598,,,fee schedule,,,7598,,,fee schedule,,,,,,,,,8936.63,,,percent of total billed charges,,Paid in addition to outpatient services ,6914.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX STRONTIUM 89 THR MCI,3412855,CDM,344,RC,A9600,HCPCS,701,APC,,,,outpatient,facility,,,7598,7598,4146.34,5597.55,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4146.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4146.34,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5597.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4146.34,,,fee schedule,,,4146.34,,,fee schedule,,,,,,,,
RRX EXAMETAZIME DX 0 25MCI DOSE,3412863,CDM,343,RC,A9521,HCPCS,,,,,,inpatient,facility,,,1813,761.46,1541.05,1740.48,,1541.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1577.31,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX EXAMETAZIME DX 0 25MCI DOSE,3412863,CDM,343,RC,A9521,HCPCS,,,,,,outpatient,facility,,,1813,761.46,489.51,3434.86,,1541.05,,,percent of total billed charges,,,489.51,,,percent of total billed charges,,,1247.34,,,percent of total billed charges,,,1220.15,,,percent of total billed charges,,,1531.98,,,percent of total billed charges,,,,,,,,,1577.31,,,percent of total billed charges,,,1577.31,,,percent of total billed charges,,,1541.05,,,percent of total billed charges,,,1740.48,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,1631.7,,,percent of total billed charges,,,,,,,,,1686.09,,,percent of total billed charges,,,1722.35,,,percent of total billed charges,,,,,,,,,,,,,,,1813,,,fee schedule,,,1813,,,fee schedule,,,1813,,,fee schedule,,,,,,,,,3434.86,,,percent of total billed charges,,Paid in addition to outpatient services ,1649.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX INF IV RMA,3412889,CDM,342,RC,79403,CPT,,,,,,inpatient,facility,,,1350,567,1147.5,1296,,1147.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1174.5,,,percent of total billed charges,,,,,,,,,1215,,,percent of total billed charges,,,1296,,,percent of total billed charges,,,1282.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1255.5,,,percent of total billed charges,,,1282.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
THERAPY RRX INF IV RMA,3412889,CDM,342,RC,79403,CPT,,,,,,outpatient,facility,,,1350,567,248.79,1296,,1147.5,,,percent of total billed charges,,,364.5,,,percent of total billed charges,,,928.8,,,percent of total billed charges,,,908.55,,,percent of total billed charges,,,1140.75,,,percent of total billed charges,,,,,,,,,1174.5,,,percent of total billed charges,,,1174.5,,,percent of total billed charges,,,1147.5,,,percent of total billed charges,,,1296,,,percent of total billed charges,,,1282.5,,,percent of total billed charges,,,,,,,,,1215,,,percent of total billed charges,,,,,,,,,1255.5,,,percent of total billed charges,,,1282.5,,,percent of total billed charges,,,,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,248.79,,,fee schedule,,,,,,,,,1054.35,,,percent of total billed charges,,,1228.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
THERAPY RRX INF IV RMA,3412889,CDM,342,RC,79403,CPT,5661,APC,,,,outpatient,facility,,,1350,1350,135.65,368.11,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,258.95,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,253.87,,,fee schedule,,,,,,,,,,,,,,,368.11,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",342.72,,,fee schedule,,,,,,,,,,,,,,,,,,,,,253.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,253.87,,,fee schedule,,,253.87,,,fee schedule,,,135.65,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RRX I 125 IOTHALAM DX 0 10UCI DOSE,3413093,CDM,343,RC,A9554,HCPCS,,,,,,inpatient,facility,,,73.1,30.7,62.13,70.18,,62.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,63.6,,,percent of total billed charges,,,,,,,,,65.79,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,69.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,67.98,,,percent of total billed charges,,,69.44,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX I 125 IOTHALAM DX 0 10UCI DOSE,3413093,CDM,343,RC,A9554,HCPCS,,,,,,outpatient,facility,,,73.1,30.7,19.74,80.17,,62.13,,,percent of total billed charges,,,19.74,,,percent of total billed charges,,,50.29,,,percent of total billed charges,,,49.2,,,percent of total billed charges,,,61.77,,,percent of total billed charges,,,,,,,,,63.6,,,percent of total billed charges,,,63.6,,,percent of total billed charges,,,62.13,,,percent of total billed charges,,,70.18,,,percent of total billed charges,,,69.44,,,percent of total billed charges,,,,,,,,,65.79,,,percent of total billed charges,,,,,,,,,67.98,,,percent of total billed charges,,,69.44,,,percent of total billed charges,,,,,,,,,,,,,,,73.1,,,fee schedule,,,73.1,,,fee schedule,,,73.1,,,fee schedule,,,,,,,,,80.17,,,percent of total billed charges,,Paid in addition to outpatient services ,66.52,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX MERTIATIDE DX 0 15MCI DOSE,3413101,CDM,343,RC,A9562,HCPCS,,,,,,inpatient,facility,,,619,259.98,526.15,594.24,,526.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,538.53,,,percent of total billed charges,,,,,,,,,557.1,,,percent of total billed charges,,,594.24,,,percent of total billed charges,,,588.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,575.67,,,percent of total billed charges,,,588.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX MERTIATIDE DX 0 15MCI DOSE,3413101,CDM,343,RC,A9562,HCPCS,,,,,,outpatient,facility,,,619,259.98,167.13,1700.26,,526.15,,,percent of total billed charges,,,167.13,,,percent of total billed charges,,,425.87,,,percent of total billed charges,,,416.59,,,percent of total billed charges,,,523.05,,,percent of total billed charges,,,,,,,,,538.53,,,percent of total billed charges,,,538.53,,,percent of total billed charges,,,526.15,,,percent of total billed charges,,,594.24,,,percent of total billed charges,,,588.05,,,percent of total billed charges,,,,,,,,,557.1,,,percent of total billed charges,,,,,,,,,575.67,,,percent of total billed charges,,,588.05,,,percent of total billed charges,,,,,,,,,,,,,,,619,,,fee schedule,,,619,,,fee schedule,,,619,,,fee schedule,,,,,,,,,1700.26,,,percent of total billed charges,,Paid in addition to outpatient services ,563.29,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX PYROPHOSPHATE DX 0 25MCI DOSE,3413143,CDM,343,RC,A9538,HCPCS,,,,,,inpatient,facility,,,165,69.3,140.25,158.4,,140.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,143.55,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,153.45,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX PYROPHOSPHATE DX 0 25MCI DOSE,3413143,CDM,343,RC,A9538,HCPCS,,,,,,outpatient,facility,,,165,69.3,44.55,165,,140.25,,,percent of total billed charges,,,44.55,,,percent of total billed charges,,,113.52,,,percent of total billed charges,,,111.04,,,percent of total billed charges,,,139.42,,,percent of total billed charges,,,,,,,,,143.55,,,percent of total billed charges,,,143.55,,,percent of total billed charges,,,140.25,,,percent of total billed charges,,,158.4,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,148.5,,,percent of total billed charges,,,,,,,,,153.45,,,percent of total billed charges,,,156.75,,,percent of total billed charges,,,,,,,,,,,,,,,165,,,fee schedule,,,165,,,fee schedule,,,165,,,fee schedule,,,,,,,,,96.64,,,percent of total billed charges,,Paid in addition to outpatient services ,150.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX MEBROFENIN DX 0 15MCI DOSE,3413168,CDM,343,RC,A9537,HCPCS,,,,,,inpatient,facility,,,413,173.46,351.05,396.48,,351.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,359.31,,,percent of total billed charges,,,,,,,,,371.7,,,percent of total billed charges,,,396.48,,,percent of total billed charges,,,392.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,384.09,,,percent of total billed charges,,,392.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX MEBROFENIN DX 0 15MCI DOSE,3413168,CDM,343,RC,A9537,HCPCS,,,,,,outpatient,facility,,,413,173.46,111.51,413,,351.05,,,percent of total billed charges,,,111.51,,,percent of total billed charges,,,284.14,,,percent of total billed charges,,,277.95,,,percent of total billed charges,,,348.99,,,percent of total billed charges,,,,,,,,,359.31,,,percent of total billed charges,,,359.31,,,percent of total billed charges,,,351.05,,,percent of total billed charges,,,396.48,,,percent of total billed charges,,,392.35,,,percent of total billed charges,,,,,,,,,371.7,,,percent of total billed charges,,,,,,,,,384.09,,,percent of total billed charges,,,392.35,,,percent of total billed charges,,,,,,,,,,,,,,,413,,,fee schedule,,,413,,,fee schedule,,,413,,,fee schedule,,,,,,,,,243.94,,,percent of total billed charges,,Paid in addition to outpatient services ,375.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX SUCCIMER DX 0 10MCI DOSE,3413176,CDM,343,RC,A9551,HCPCS,,,,,,inpatient,facility,,,536,225.12,455.6,514.56,,455.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,466.32,,,percent of total billed charges,,,,,,,,,482.4,,,percent of total billed charges,,,514.56,,,percent of total billed charges,,,509.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,498.48,,,percent of total billed charges,,,509.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX SUCCIMER DX 0 10MCI DOSE,3413176,CDM,343,RC,A9551,HCPCS,,,,,,outpatient,facility,,,536,225.12,144.72,1504.1,,455.6,,,percent of total billed charges,,,144.72,,,percent of total billed charges,,,368.77,,,percent of total billed charges,,,360.73,,,percent of total billed charges,,,452.92,,,percent of total billed charges,,,,,,,,,466.32,,,percent of total billed charges,,,466.32,,,percent of total billed charges,,,455.6,,,percent of total billed charges,,,514.56,,,percent of total billed charges,,,509.2,,,percent of total billed charges,,,,,,,,,482.4,,,percent of total billed charges,,,,,,,,,498.48,,,percent of total billed charges,,,509.2,,,percent of total billed charges,,,,,,,,,,,,,,,536,,,fee schedule,,,536,,,fee schedule,,,536,,,fee schedule,,,,,,,,,1504.1,,,percent of total billed charges,,Paid in addition to outpatient services ,487.76,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX MAA DX 0 10MCI DOSE,3413200,CDM,343,RC,A9540,HCPCS,,,,,,inpatient,facility,,,513,215.46,436.05,492.48,,436.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,446.31,,,percent of total billed charges,,,,,,,,,461.7,,,percent of total billed charges,,,492.48,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,477.09,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX MAA DX 0 10MCI DOSE,3413200,CDM,343,RC,A9540,HCPCS,,,,,,outpatient,facility,,,513,215.46,70.15,513,,436.05,,,percent of total billed charges,,,138.51,,,percent of total billed charges,,,352.94,,,percent of total billed charges,,,345.25,,,percent of total billed charges,,,433.49,,,percent of total billed charges,,,,,,,,,446.31,,,percent of total billed charges,,,446.31,,,percent of total billed charges,,,436.05,,,percent of total billed charges,,,492.48,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,,,,,,,,461.7,,,percent of total billed charges,,,,,,,,,477.09,,,percent of total billed charges,,,487.35,,,percent of total billed charges,,,,,,,,,,,,,,,513,,,fee schedule,,,513,,,fee schedule,,,513,,,fee schedule,,,,,,,,,70.15,,,percent of total billed charges,,Paid in addition to outpatient services ,466.83,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX BICISATE DX 0 25MCI DOSE,3413218,CDM,343,RC,A9557,HCPCS,,,,,,inpatient,facility,,,3395,1425.9,2885.75,3259.2,,2885.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2953.65,,,percent of total billed charges,,,,,,,,,3055.5,,,percent of total billed charges,,,3259.2,,,percent of total billed charges,,,3225.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,3157.35,,,percent of total billed charges,,,3225.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX BICISATE DX 0 25MCI DOSE,3413218,CDM,343,RC,A9557,HCPCS,,,,,,outpatient,facility,,,3395,1425.9,916.65,3447.03,,2885.75,,,percent of total billed charges,,,916.65,,,percent of total billed charges,,,2335.76,,,percent of total billed charges,,,2284.83,,,percent of total billed charges,,,2868.78,,,percent of total billed charges,,,,,,,,,2953.65,,,percent of total billed charges,,,2953.65,,,percent of total billed charges,,,2885.75,,,percent of total billed charges,,,3259.2,,,percent of total billed charges,,,3225.25,,,percent of total billed charges,,,,,,,,,3055.5,,,percent of total billed charges,,,,,,,,,3157.35,,,percent of total billed charges,,,3225.25,,,percent of total billed charges,,,,,,,,,,,,,,,3395,,,fee schedule,,,3395,,,fee schedule,,,3395,,,fee schedule,,,,,,,,,3447.03,,,percent of total billed charges,,Paid in addition to outpatient services ,3089.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX SULFUR COLLOID DX 0 20MCI DOSE,3413226,CDM,343,RC,A9541,HCPCS,,,,,,inpatient,facility,,,608,255.36,516.8,583.68,,516.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,528.96,,,percent of total billed charges,,,,,,,,,547.2,,,percent of total billed charges,,,583.68,,,percent of total billed charges,,,577.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,565.44,,,percent of total billed charges,,,577.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX SULFUR COLLOID DX 0 20MCI DOSE,3413226,CDM,343,RC,A9541,HCPCS,,,,,,outpatient,facility,,,608,255.36,164.16,775.31,,516.8,,,percent of total billed charges,,,164.16,,,percent of total billed charges,,,418.3,,,percent of total billed charges,,,409.18,,,percent of total billed charges,,,513.76,,,percent of total billed charges,,,,,,,,,528.96,,,percent of total billed charges,,,528.96,,,percent of total billed charges,,,516.8,,,percent of total billed charges,,,583.68,,,percent of total billed charges,,,577.6,,,percent of total billed charges,,,,,,,,,547.2,,,percent of total billed charges,,,,,,,,,565.44,,,percent of total billed charges,,,577.6,,,percent of total billed charges,,,,,,,,,,,,,,,608,,,fee schedule,,,608,,,fee schedule,,,608,,,fee schedule,,,,,,,,,775.31,,,percent of total billed charges,,Paid in addition to outpatient services ,553.28,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX RBC LABELED DX 0 30MCI DOSE,3413234,CDM,343,RC,A9560,HCPCS,,,,,,inpatient,facility,,,614,257.88,521.9,589.44,,521.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,534.18,,,percent of total billed charges,,,,,,,,,552.6,,,percent of total billed charges,,,589.44,,,percent of total billed charges,,,583.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,571.02,,,percent of total billed charges,,,583.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX RBC LABELED DX 0 30MCI DOSE,3413234,CDM,343,RC,A9560,HCPCS,,,,,,outpatient,facility,,,614,257.88,165.78,614,,521.9,,,percent of total billed charges,,,165.78,,,percent of total billed charges,,,422.43,,,percent of total billed charges,,,413.22,,,percent of total billed charges,,,518.83,,,percent of total billed charges,,,,,,,,,534.18,,,percent of total billed charges,,,534.18,,,percent of total billed charges,,,521.9,,,percent of total billed charges,,,589.44,,,percent of total billed charges,,,583.3,,,percent of total billed charges,,,,,,,,,552.6,,,percent of total billed charges,,,,,,,,,571.02,,,percent of total billed charges,,,583.3,,,percent of total billed charges,,,,,,,,,,,,,,,614,,,fee schedule,,,614,,,fee schedule,,,614,,,fee schedule,,,,,,,,,220.5,,,percent of total billed charges,,Paid in addition to outpatient services ,558.74,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX OXIDRONATE DX 0 30MCI DOSE,3413325,CDM,343,RC,A9561,HCPCS,,,,,,inpatient,facility,,,556,233.52,472.6,533.76,,472.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,483.72,,,percent of total billed charges,,,,,,,,,500.4,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX OXIDRONATE DX 0 30MCI DOSE,3413325,CDM,343,RC,A9561,HCPCS,,,,,,outpatient,facility,,,556,233.52,111.67,556,,472.6,,,percent of total billed charges,,,150.12,,,percent of total billed charges,,,382.53,,,percent of total billed charges,,,374.19,,,percent of total billed charges,,,469.82,,,percent of total billed charges,,,,,,,,,483.72,,,percent of total billed charges,,,483.72,,,percent of total billed charges,,,472.6,,,percent of total billed charges,,,533.76,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,500.4,,,percent of total billed charges,,,,,,,,,517.08,,,percent of total billed charges,,,528.2,,,percent of total billed charges,,,,,,,,,,,,,,,556,,,fee schedule,,,556,,,fee schedule,,,556,,,fee schedule,,,,,,,,,111.67,,,percent of total billed charges,,Paid in addition to outpatient services ,505.96,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BRAIN 1 3 VW STATIC,3413382,CDM,341,RC,78600,CPT,,,,,,inpatient,facility,,,781,328.02,663.85,749.76,,663.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,679.47,,,percent of total billed charges,,,,,,,,,702.9,,,percent of total billed charges,,,749.76,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,726.33,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BRAIN 1 3 VW STATIC,3413382,CDM,341,RC,78600,CPT,,,,,,outpatient,facility,,,781,328.02,210.87,749.76,,663.85,,,percent of total billed charges,,,210.87,,,percent of total billed charges,,,537.33,,,percent of total billed charges,,,525.61,,,percent of total billed charges,,,659.94,,,percent of total billed charges,,,,,,,,,679.47,,,percent of total billed charges,,,679.47,,,percent of total billed charges,,,663.85,,,percent of total billed charges,,,749.76,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,702.9,,,percent of total billed charges,,,,,,,,,726.33,,,percent of total billed charges,,,741.95,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,609.96,,,percent of total billed charges,,,710.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BRAIN 1 3 VW STATIC,3413382,CDM,341,RC,78600,CPT,5591,APC,,,,outpatient,facility,,,781,781,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM BRAIN 1 3 VW STATIC W FLOW,3413390,CDM,341,RC,78601,CPT,,,,,,inpatient,facility,,,917,385.14,779.45,880.32,,779.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,797.79,,,percent of total billed charges,,,,,,,,,825.3,,,percent of total billed charges,,,880.32,,,percent of total billed charges,,,871.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,852.81,,,percent of total billed charges,,,871.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BRAIN 1 3 VW STATIC W FLOW,3413390,CDM,341,RC,78601,CPT,,,,,,outpatient,facility,,,917,385.14,247.59,880.32,,779.45,,,percent of total billed charges,,,247.59,,,percent of total billed charges,,,630.9,,,percent of total billed charges,,,617.14,,,percent of total billed charges,,,774.87,,,percent of total billed charges,,,,,,,,,797.79,,,percent of total billed charges,,,797.79,,,percent of total billed charges,,,779.45,,,percent of total billed charges,,,880.32,,,percent of total billed charges,,,871.15,,,percent of total billed charges,,,,,,,,,825.3,,,percent of total billed charges,,,,,,,,,852.81,,,percent of total billed charges,,,871.15,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,716.18,,,percent of total billed charges,,,834.47,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BRAIN 1 3 VW STATIC W FLOW,3413390,CDM,341,RC,78601,CPT,5591,APC,,,,outpatient,facility,,,917,917,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM BRAIN 4 PLUS VW STATIC,3413408,CDM,341,RC,78605,CPT,,,,,,inpatient,facility,,,837,351.54,711.45,803.52,,711.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,728.19,,,percent of total billed charges,,,,,,,,,753.3,,,percent of total billed charges,,,803.52,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,778.41,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BRAIN 4 PLUS VW STATIC,3413408,CDM,341,RC,78605,CPT,,,,,,outpatient,facility,,,837,351.54,225.99,803.52,,711.45,,,percent of total billed charges,,,225.99,,,percent of total billed charges,,,575.86,,,percent of total billed charges,,,563.3,,,percent of total billed charges,,,707.26,,,percent of total billed charges,,,,,,,,,728.19,,,percent of total billed charges,,,728.19,,,percent of total billed charges,,,711.45,,,percent of total billed charges,,,803.52,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,753.3,,,percent of total billed charges,,,,,,,,,778.41,,,percent of total billed charges,,,795.15,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,653.7,,,percent of total billed charges,,,761.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BRAIN 4 PLUS VW STATIC,3413408,CDM,341,RC,78605,CPT,5592,APC,,,,outpatient,facility,,,837,837,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM BRAIN 4 PLUS VW STATIC W FLOW,3413416,CDM,341,RC,78606,CPT,,,,,,inpatient,facility,,,1390,583.8,1181.5,1334.4,,1181.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1209.3,,,percent of total billed charges,,,,,,,,,1251,,,percent of total billed charges,,,1334.4,,,percent of total billed charges,,,1320.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1292.7,,,percent of total billed charges,,,1320.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM BRAIN 4 PLUS VW STATIC W FLOW,3413416,CDM,341,RC,78606,CPT,,,,,,outpatient,facility,,,1390,583.8,375.3,1334.4,,1181.5,,,percent of total billed charges,,,375.3,,,percent of total billed charges,,,956.32,,,percent of total billed charges,,,935.47,,,percent of total billed charges,,,1174.55,,,percent of total billed charges,,,,,,,,,1209.3,,,percent of total billed charges,,,1209.3,,,percent of total billed charges,,,1181.5,,,percent of total billed charges,,,1334.4,,,percent of total billed charges,,,1320.5,,,percent of total billed charges,,,,,,,,,1251,,,percent of total billed charges,,,,,,,,,1292.7,,,percent of total billed charges,,,1320.5,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1085.59,,,percent of total billed charges,,,1264.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM BRAIN 4 PLUS VW STATIC W FLOW,3413416,CDM,341,RC,78606,CPT,5592,APC,,,,outpatient,facility,,,1390,1390,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RRX I 123 IOD NA DX MCI,3413440,CDM,343,RC,A9509,HCPCS,,,,,,inpatient,facility,,,1639,688.38,1393.15,1573.44,,1393.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1425.93,,,percent of total billed charges,,,,,,,,,1475.1,,,percent of total billed charges,,,1573.44,,,percent of total billed charges,,,1557.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1524.27,,,percent of total billed charges,,,1557.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX I 123 IOD NA DX MCI,3413440,CDM,343,RC,A9509,HCPCS,,,,,,outpatient,facility,,,1639,688.38,396.61,1639,,1393.15,,,percent of total billed charges,,,442.53,,,percent of total billed charges,,,1127.63,,,percent of total billed charges,,,1103.05,,,percent of total billed charges,,,1384.95,,,percent of total billed charges,,,,,,,,,1425.93,,,percent of total billed charges,,,1425.93,,,percent of total billed charges,,,1393.15,,,percent of total billed charges,,,1573.44,,,percent of total billed charges,,,1557.05,,,percent of total billed charges,,,,,,,,,1475.1,,,percent of total billed charges,,,,,,,,,1524.27,,,percent of total billed charges,,,1557.05,,,percent of total billed charges,,,,,,,,,,,,,,,1639,,,fee schedule,,,1639,,,fee schedule,,,1639,,,fee schedule,,,,,,,,,396.61,,,percent of total billed charges,,Paid in addition to outpatient services ,1491.49,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX I 123 IOD NA DX 100UCI  LESS THAN1MCI,3413457,CDM,343,RC,A9516,HCPCS,,,,,,inpatient,facility,,,381,160.02,323.85,365.76,,323.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,331.47,,,percent of total billed charges,,,,,,,,,342.9,,,percent of total billed charges,,,365.76,,,percent of total billed charges,,,361.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,354.33,,,percent of total billed charges,,,361.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX I 123 IOD NA DX 100UCI  LESS THAN1MCI,3413457,CDM,343,RC,A9516,HCPCS,,,,,,outpatient,facility,,,381,160.02,102.87,381,,323.85,,,percent of total billed charges,,,102.87,,,percent of total billed charges,,,262.13,,,percent of total billed charges,,,256.41,,,percent of total billed charges,,,321.94,,,percent of total billed charges,,,,,,,,,331.47,,,percent of total billed charges,,,331.47,,,percent of total billed charges,,,323.85,,,percent of total billed charges,,,365.76,,,percent of total billed charges,,,361.95,,,percent of total billed charges,,,,,,,,,342.9,,,percent of total billed charges,,,,,,,,,354.33,,,percent of total billed charges,,,361.95,,,percent of total billed charges,,,,,,,,,,,,,,,381,,,fee schedule,,,381,,,fee schedule,,,381,,,fee schedule,,,,,,,,,246.99,,,percent of total billed charges,,Paid in addition to outpatient services ,346.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 PENTET DX 0 6MCI,3413465,CDM,343,RC,A9572,HCPCS,,,,,,inpatient,facility,,,12397,5206.74,10537.45,11901.12,,10537.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10785.39,,,percent of total billed charges,,,,,,,,,11157.3,,,percent of total billed charges,,,11901.12,,,percent of total billed charges,,,11777.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11529.21,,,percent of total billed charges,,,11777.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 PENTET DX 0 6MCI,3413465,CDM,343,RC,A9572,HCPCS,,,,,,outpatient,facility,,,12397,5206.74,3347.19,13566.24,,10537.45,,,percent of total billed charges,,,3347.19,,,percent of total billed charges,,,8529.14,,,percent of total billed charges,,,8343.18,,,percent of total billed charges,,,10475.47,,,percent of total billed charges,,,,,,,,,10785.39,,,percent of total billed charges,,,10785.39,,,percent of total billed charges,,,10537.45,,,percent of total billed charges,,,11901.12,,,percent of total billed charges,,,11777.15,,,percent of total billed charges,,,,,,,,,11157.3,,,percent of total billed charges,,,,,,,,,11529.21,,,percent of total billed charges,,,11777.15,,,percent of total billed charges,,,,,,,,,,,,,,,12397,,,fee schedule,,,12397,,,fee schedule,,,12397,,,fee schedule,,,,,,,,,13566.24,,,percent of total billed charges,,Paid in addition to outpatient services ,11281.27,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX EXAMETAZIME WBC LABELED DX DOSE,3413473,CDM,343,RC,A9569,HCPCS,,,,,,inpatient,facility,,,6434,2702.28,5468.9,6176.64,,5468.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5597.58,,,percent of total billed charges,,,,,,,,,5790.6,,,percent of total billed charges,,,6176.64,,,percent of total billed charges,,,6112.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5983.62,,,percent of total billed charges,,,6112.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX EXAMETAZIME WBC LABELED DX DOSE,3413473,CDM,343,RC,A9569,HCPCS,,,,,,outpatient,facility,,,6434,2702.28,1737.18,6434,,5468.9,,,percent of total billed charges,,,1737.18,,,percent of total billed charges,,,4426.59,,,percent of total billed charges,,,4330.08,,,percent of total billed charges,,,5436.73,,,percent of total billed charges,,,,,,,,,5597.58,,,percent of total billed charges,,,5597.58,,,percent of total billed charges,,,5468.9,,,percent of total billed charges,,,6176.64,,,percent of total billed charges,,,6112.3,,,percent of total billed charges,,,,,,,,,5790.6,,,percent of total billed charges,,,,,,,,,5983.62,,,percent of total billed charges,,,6112.3,,,percent of total billed charges,,,,,,,,,,,,,,,6434,,,fee schedule,,,6434,,,fee schedule,,,6434,,,fee schedule,,,,,,,,,3841.49,,,percent of total billed charges,,Paid in addition to outpatient services ,5854.94,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 WBC LABELED DX DOSE,3413481,CDM,343,RC,A9570,HCPCS,,,,,,inpatient,facility,,,4609,1935.78,3917.65,4424.64,,3917.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4009.83,,,percent of total billed charges,,,,,,,,,4148.1,,,percent of total billed charges,,,4424.64,,,percent of total billed charges,,,4378.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,4286.37,,,percent of total billed charges,,,4378.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX INDIUM 111 WBC LABELED DX DOSE,3413481,CDM,343,RC,A9570,HCPCS,,,,,,outpatient,facility,,,4609,1935.78,1244.43,8923.64,,3917.65,,,percent of total billed charges,,,1244.43,,,percent of total billed charges,,,3170.99,,,percent of total billed charges,,,3101.86,,,percent of total billed charges,,,3894.61,,,percent of total billed charges,,,,,,,,,4009.83,,,percent of total billed charges,,,4009.83,,,percent of total billed charges,,,3917.65,,,percent of total billed charges,,,4424.64,,,percent of total billed charges,,,4378.55,,,percent of total billed charges,,,,,,,,,4148.1,,,percent of total billed charges,,,,,,,,,4286.37,,,percent of total billed charges,,,4378.55,,,percent of total billed charges,,,,,,,,,,,,,,,4609,,,fee schedule,,,4609,,,fee schedule,,,4609,,,fee schedule,,,,,,,,,8923.64,,,percent of total billed charges,,Paid in addition to outpatient services ,4194.19,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ RRX LOC STDY PROBE NON IMG IV,3413515,CDM,341,RC,78808,CPT,,,,,,inpatient,facility,,,330,138.6,280.5,316.8,,280.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,287.1,,,percent of total billed charges,,,,,,,,,297,,,percent of total billed charges,,,316.8,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,306.9,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ RRX LOC STDY PROBE NON IMG IV,3413515,CDM,341,RC,78808,CPT,,,,,,outpatient,facility,,,330,138.6,89.1,420.87,,280.5,,,percent of total billed charges,,,89.1,,,percent of total billed charges,,,227.04,,,percent of total billed charges,,,222.09,,,percent of total billed charges,,,278.85,,,percent of total billed charges,,,,,,,,,287.1,,,percent of total billed charges,,,287.1,,,percent of total billed charges,,,280.5,,,percent of total billed charges,,,316.8,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,297,,,percent of total billed charges,,,,,,,,,306.9,,,percent of total billed charges,,,313.5,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,257.73,,,percent of total billed charges,,,300.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ RRX LOC STDY PROBE NON IMG IV,3413515,CDM,341,RC,78808,CPT,5591,APC,,,,outpatient,facility,,,330,330,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PERF MYOC SPECT WM EF SGL,3413572,CDM,341,RC,78451,CPT,,,,,,inpatient,facility,,,785,329.7,667.25,753.6,,667.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.95,,,percent of total billed charges,,,,,,,,,706.5,,,percent of total billed charges,,,753.6,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,730.05,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC SPECT WM EF SGL,3413572,CDM,341,RC,78451,CPT,,,,,,outpatient,facility,,,785,329.7,211.95,1448.99,,667.25,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,540.08,,,percent of total billed charges,,,528.3,,,percent of total billed charges,,,663.32,,,percent of total billed charges,,,,,,,,,682.95,,,percent of total billed charges,,,682.95,,,percent of total billed charges,,,667.25,,,percent of total billed charges,,,753.6,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,730.05,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,613.08,,,percent of total billed charges,,,714.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC SPECT WM EF SGL,3413572,CDM,341,RC,78451,CPT,5593,APC,,,,outpatient,facility,,,785,785,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PERF MYOC SPEC WM EF MULT,3413580,CDM,341,RC,78452,CPT,,,,,,inpatient,facility,,,946,397.32,804.1,908.16,,804.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.02,,,percent of total billed charges,,,,,,,,,851.4,,,percent of total billed charges,,,908.16,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,879.78,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC SPEC WM EF MULT,3413580,CDM,341,RC,78452,CPT,,,,,,outpatient,facility,,,946,397.32,255.42,1448.99,,804.1,,,percent of total billed charges,,,255.42,,,percent of total billed charges,,,650.85,,,percent of total billed charges,,,636.66,,,percent of total billed charges,,,799.37,,,percent of total billed charges,,,,,,,,,823.02,,,percent of total billed charges,,,823.02,,,percent of total billed charges,,,804.1,,,percent of total billed charges,,,908.16,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,851.4,,,percent of total billed charges,,,,,,,,,879.78,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,738.83,,,percent of total billed charges,,,860.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC SPEC WM EF MULT,3413580,CDM,341,RC,78452,CPT,5593,APC,,,,outpatient,facility,,,946,946,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PERF MYOC PLANAR WM EF SGL,3413598,CDM,341,RC,78453,CPT,,,,,,inpatient,facility,,,785,329.7,667.25,753.6,,667.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,682.95,,,percent of total billed charges,,,,,,,,,706.5,,,percent of total billed charges,,,753.6,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,730.05,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC PLANAR WM EF SGL,3413598,CDM,341,RC,78453,CPT,,,,,,outpatient,facility,,,785,329.7,211.95,1448.99,,667.25,,,percent of total billed charges,,,211.95,,,percent of total billed charges,,,540.08,,,percent of total billed charges,,,528.3,,,percent of total billed charges,,,663.32,,,percent of total billed charges,,,,,,,,,682.95,,,percent of total billed charges,,,682.95,,,percent of total billed charges,,,667.25,,,percent of total billed charges,,,753.6,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,706.5,,,percent of total billed charges,,,,,,,,,730.05,,,percent of total billed charges,,,745.75,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,613.08,,,percent of total billed charges,,,714.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC PLANAR WM EF SGL,3413598,CDM,341,RC,78453,CPT,5593,APC,,,,outpatient,facility,,,785,785,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PERF MYOC PLANAR WM EF MULT,3413606,CDM,341,RC,78454,CPT,,,,,,inpatient,facility,,,946,397.32,804.1,908.16,,804.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,823.02,,,percent of total billed charges,,,,,,,,,851.4,,,percent of total billed charges,,,908.16,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,879.78,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC PLANAR WM EF MULT,3413606,CDM,341,RC,78454,CPT,,,,,,outpatient,facility,,,946,397.32,255.42,1448.99,,804.1,,,percent of total billed charges,,,255.42,,,percent of total billed charges,,,650.85,,,percent of total billed charges,,,636.66,,,percent of total billed charges,,,799.37,,,percent of total billed charges,,,,,,,,,823.02,,,percent of total billed charges,,,823.02,,,percent of total billed charges,,,804.1,,,percent of total billed charges,,,908.16,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,851.4,,,percent of total billed charges,,,,,,,,,879.78,,,percent of total billed charges,,,898.7,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,738.83,,,percent of total billed charges,,,860.86,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PERF MYOC PLANAR WM EF MULT,3413606,CDM,341,RC,78454,CPT,5593,APC,,,,outpatient,facility,,,946,946,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ RRX NODE SENTINEL ID BI,3413762,CDM,361,RC,38792,CPT,,,,,50,inpatient,facility,,,996,418.32,846.6,956.16,,846.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,866.52,,,percent of total billed charges,,,,,,,,,896.4,,,percent of total billed charges,,,956.16,,,percent of total billed charges,,,946.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,926.28,,,percent of total billed charges,,,946.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ RRX NODE SENTINEL ID BI,3413762,CDM,361,RC,38792,CPT,,,,,50,outpatient,facility,,,996,418.32,268.92,3428,,846.6,,,percent of total billed charges,,,268.92,,,percent of total billed charges,,,685.25,,,percent of total billed charges,,,670.31,,,percent of total billed charges,,,841.62,,,percent of total billed charges,,,,,,,,,866.52,,,percent of total billed charges,,,866.52,,,percent of total billed charges,,,846.6,,,percent of total billed charges,,,956.16,,,percent of total billed charges,,,946.2,,,percent of total billed charges,,,,,,,,,896.4,,,percent of total billed charges,,,,,,,,,926.28,,,percent of total billed charges,,,946.2,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,906.36,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ RRX NODE SENTINEL ID BI,3413762,CDM,361,RC,38792,CPT,5591,APC,,,50,outpatient,facility,,,996,996,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ RRX NODE SENTINEL ID LT,3413770,CDM,361,RC,38792,CPT,,,,,LT  ,inpatient,facility,,,664,278.88,564.4,637.44,,564.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.68,,,percent of total billed charges,,,,,,,,,597.6,,,percent of total billed charges,,,637.44,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.52,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ RRX NODE SENTINEL ID LT,3413770,CDM,361,RC,38792,CPT,,,,,LT  ,outpatient,facility,,,664,278.88,179.28,3428,,564.4,,,percent of total billed charges,,,179.28,,,percent of total billed charges,,,456.83,,,percent of total billed charges,,,446.87,,,percent of total billed charges,,,561.08,,,percent of total billed charges,,,,,,,,,577.68,,,percent of total billed charges,,,577.68,,,percent of total billed charges,,,564.4,,,percent of total billed charges,,,637.44,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,597.6,,,percent of total billed charges,,,,,,,,,617.52,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,604.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ RRX NODE SENTINEL ID LT,3413770,CDM,361,RC,38792,CPT,5591,APC,,,LT  ,outpatient,facility,,,664,664,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
INJ RRX NODE SENTINEL ID RT,3413788,CDM,361,RC,38792,CPT,,,,,RT  ,inpatient,facility,,,664,278.88,564.4,637.44,,564.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,577.68,,,percent of total billed charges,,,,,,,,,597.6,,,percent of total billed charges,,,637.44,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,617.52,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
INJ RRX NODE SENTINEL ID RT,3413788,CDM,361,RC,38792,CPT,,,,,RT  ,outpatient,facility,,,664,278.88,179.28,3428,,564.4,,,percent of total billed charges,,,179.28,,,percent of total billed charges,,,456.83,,,percent of total billed charges,,,446.87,,,percent of total billed charges,,,561.08,,,percent of total billed charges,,,,,,,,,577.68,,,percent of total billed charges,,,577.68,,,percent of total billed charges,,,564.4,,,percent of total billed charges,,,637.44,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,597.6,,,percent of total billed charges,,,,,,,,,617.52,,,percent of total billed charges,,,630.8,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,3428,,,percent of total billed charges,,,604.24,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
INJ RRX NODE SENTINEL ID RT,3413788,CDM,361,RC,38792,CPT,5591,APC,,,RT  ,outpatient,facility,,,664,664,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM HEPATOBILIARY W WO GB,3413796,CDM,341,RC,78226,CPT,,,,,,inpatient,facility,,,1783,748.86,1515.55,1711.68,,1515.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1551.21,,,percent of total billed charges,,,,,,,,,1604.7,,,percent of total billed charges,,,1711.68,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1658.19,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM HEPATOBILIARY W WO GB,3413796,CDM,341,RC,78226,CPT,,,,,,outpatient,facility,,,1783,748.86,412.45,1711.68,,1515.55,,,percent of total billed charges,,,481.41,,,percent of total billed charges,,,1226.7,,,percent of total billed charges,,,1199.96,,,percent of total billed charges,,,1506.63,,,percent of total billed charges,,,,,,,,,1551.21,,,percent of total billed charges,,,1551.21,,,percent of total billed charges,,,1515.55,,,percent of total billed charges,,,1711.68,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,1604.7,,,percent of total billed charges,,,,,,,,,1658.19,,,percent of total billed charges,,,1693.85,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1392.52,,,percent of total billed charges,,,1622.53,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM HEPATOBILIARY W WO GB,3413796,CDM,341,RC,78226,CPT,5591,APC,,,,outpatient,facility,,,1783,1783,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM HEPATOBILIARY W PHARM W WO GB,3413804,CDM,341,RC,78227,CPT,,,,,,inpatient,facility,,,2443,1026.06,2076.55,2345.28,,2076.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2125.41,,,percent of total billed charges,,,,,,,,,2198.7,,,percent of total billed charges,,,2345.28,,,percent of total billed charges,,,2320.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2271.99,,,percent of total billed charges,,,2320.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM HEPATOBILIARY W PHARM W WO GB,3413804,CDM,341,RC,78227,CPT,,,,,,outpatient,facility,,,2443,1026.06,540.52,2345.28,,2076.55,,,percent of total billed charges,,,659.61,,,percent of total billed charges,,,1680.78,,,percent of total billed charges,,,1644.14,,,percent of total billed charges,,,2064.34,,,percent of total billed charges,,,,,,,,,2125.41,,,percent of total billed charges,,,2125.41,,,percent of total billed charges,,,2076.55,,,percent of total billed charges,,,2345.28,,,percent of total billed charges,,,2320.85,,,percent of total billed charges,,,,,,,,,2198.7,,,percent of total billed charges,,,,,,,,,2271.99,,,percent of total billed charges,,,2320.85,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1907.98,,,percent of total billed charges,,,2223.13,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM HEPATOBILIARY W PHARM W WO GB,3413804,CDM,341,RC,78227,CPT,5592,APC,,,,outpatient,facility,,,2443,2443,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM VENT PULMONARY,3413812,CDM,341,RC,78579,CPT,,,,,,inpatient,facility,,,1026,430.92,872.1,984.96,,872.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,892.62,,,percent of total billed charges,,,,,,,,,923.4,,,percent of total billed charges,,,984.96,,,percent of total billed charges,,,974.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,954.18,,,percent of total billed charges,,,974.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM VENT PULMONARY,3413812,CDM,341,RC,78579,CPT,,,,,,outpatient,facility,,,1026,430.92,277.02,984.96,,872.1,,,percent of total billed charges,,,277.02,,,percent of total billed charges,,,705.89,,,percent of total billed charges,,,690.5,,,percent of total billed charges,,,866.97,,,percent of total billed charges,,,,,,,,,892.62,,,percent of total billed charges,,,892.62,,,percent of total billed charges,,,872.1,,,percent of total billed charges,,,984.96,,,percent of total billed charges,,,974.7,,,percent of total billed charges,,,,,,,,,923.4,,,percent of total billed charges,,,,,,,,,954.18,,,percent of total billed charges,,,974.7,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,801.31,,,percent of total billed charges,,,933.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM VENT PULMONARY,3413812,CDM,341,RC,78579,CPT,5591,APC,,,,outpatient,facility,,,1026,1026,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM VENT ANDPERF PULMONARY,3413820,CDM,341,RC,78582,CPT,,,,,,inpatient,facility,,,1831,769.02,1556.35,1757.76,,1556.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1592.97,,,percent of total billed charges,,,,,,,,,1647.9,,,percent of total billed charges,,,1757.76,,,percent of total billed charges,,,1739.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1702.83,,,percent of total billed charges,,,1739.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM VENT ANDPERF PULMONARY,3413820,CDM,341,RC,78582,CPT,,,,,,outpatient,facility,,,1831,769.02,494.37,1757.76,,1556.35,,,percent of total billed charges,,,494.37,,,percent of total billed charges,,,1259.73,,,percent of total billed charges,,,1232.26,,,percent of total billed charges,,,1547.19,,,percent of total billed charges,,,,,,,,,1592.97,,,percent of total billed charges,,,1592.97,,,percent of total billed charges,,,1556.35,,,percent of total billed charges,,,1757.76,,,percent of total billed charges,,,1739.45,,,percent of total billed charges,,,,,,,,,1647.9,,,percent of total billed charges,,,,,,,,,1702.83,,,percent of total billed charges,,,1739.45,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1430.01,,,percent of total billed charges,,,1666.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM VENT ANDPERF PULMONARY,3413820,CDM,341,RC,78582,CPT,5592,APC,,,,outpatient,facility,,,1831,1831,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PERF PULM DIFF QN W WO IMG,3413838,CDM,341,RC,78597,CPT,,,,,,inpatient,facility,,,1189,499.38,1010.65,1141.44,,1010.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1034.43,,,percent of total billed charges,,,,,,,,,1070.1,,,percent of total billed charges,,,1141.44,,,percent of total billed charges,,,1129.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1105.77,,,percent of total billed charges,,,1129.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PERF PULM DIFF QN W WO IMG,3413838,CDM,341,RC,78597,CPT,,,,,,outpatient,facility,,,1189,499.38,321.03,1141.44,,1010.65,,,percent of total billed charges,,,321.03,,,percent of total billed charges,,,818.03,,,percent of total billed charges,,,800.2,,,percent of total billed charges,,,1004.7,,,percent of total billed charges,,,,,,,,,1034.43,,,percent of total billed charges,,,1034.43,,,percent of total billed charges,,,1010.65,,,percent of total billed charges,,,1141.44,,,percent of total billed charges,,,1129.55,,,percent of total billed charges,,,,,,,,,1070.1,,,percent of total billed charges,,,,,,,,,1105.77,,,percent of total billed charges,,,1129.55,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,928.61,,,percent of total billed charges,,,1081.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PERF PULM DIFF QN W WO IMG,3413838,CDM,341,RC,78597,CPT,5591,APC,,,,outpatient,facility,,,1189,1189,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PERF ANDVENT PULM DIFF QN W WO IMG,3413846,CDM,341,RC,78598,CPT,,,,,,inpatient,facility,,,1830,768.6,1555.5,1756.8,,1555.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1592.1,,,percent of total billed charges,,,,,,,,,1647,,,percent of total billed charges,,,1756.8,,,percent of total billed charges,,,1738.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1701.9,,,percent of total billed charges,,,1738.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PERF ANDVENT PULM DIFF QN W WO IMG,3413846,CDM,341,RC,78598,CPT,,,,,,outpatient,facility,,,1830,768.6,494.1,1756.8,,1555.5,,,percent of total billed charges,,,494.1,,,percent of total billed charges,,,1259.04,,,percent of total billed charges,,,1231.59,,,percent of total billed charges,,,1546.35,,,percent of total billed charges,,,,,,,,,1592.1,,,percent of total billed charges,,,1592.1,,,percent of total billed charges,,,1555.5,,,percent of total billed charges,,,1756.8,,,percent of total billed charges,,,1738.5,,,percent of total billed charges,,,,,,,,,1647,,,percent of total billed charges,,,,,,,,,1701.9,,,percent of total billed charges,,,1738.5,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,1429.23,,,percent of total billed charges,,,1665.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PERF ANDVENT PULM DIFF QN W WO IMG,3413846,CDM,341,RC,78598,CPT,5592,APC,,,,outpatient,facility,,,1830,1830,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM THYROID UPTAKE MEAS QN SGL MULT,3413960,CDM,341,RC,78012,CPT,,,,,,inpatient,facility,,,663,278.46,563.55,636.48,,563.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,576.81,,,percent of total billed charges,,,,,,,,,596.7,,,percent of total billed charges,,,636.48,,,percent of total billed charges,,,629.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,616.59,,,percent of total billed charges,,,629.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM THYROID UPTAKE MEAS QN SGL MULT,3413960,CDM,341,RC,78012,CPT,,,,,,outpatient,facility,,,663,278.46,179.01,636.48,,563.55,,,percent of total billed charges,,,179.01,,,percent of total billed charges,,,456.14,,,percent of total billed charges,,,446.2,,,percent of total billed charges,,,560.24,,,percent of total billed charges,,,,,,,,,576.81,,,percent of total billed charges,,,576.81,,,percent of total billed charges,,,563.55,,,percent of total billed charges,,,636.48,,,percent of total billed charges,,,629.85,,,percent of total billed charges,,,,,,,,,596.7,,,percent of total billed charges,,,,,,,,,616.59,,,percent of total billed charges,,,629.85,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,517.8,,,percent of total billed charges,,,603.33,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM THYROID UPTAKE MEAS QN SGL MULT,3413960,CDM,341,RC,78012,CPT,5591,APC,,,,outpatient,facility,,,663,663,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM THYROID W WO FLOW VASCULAR,3413978,CDM,341,RC,78013,CPT,,,,,,inpatient,facility,,,1144,480.48,972.4,1098.24,,972.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,995.28,,,percent of total billed charges,,,,,,,,,1029.6,,,percent of total billed charges,,,1098.24,,,percent of total billed charges,,,1086.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1063.92,,,percent of total billed charges,,,1086.8,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM THYROID W WO FLOW VASCULAR,3413978,CDM,341,RC,78013,CPT,,,,,,outpatient,facility,,,1144,480.48,308.88,1098.24,,972.4,,,percent of total billed charges,,,308.88,,,percent of total billed charges,,,787.07,,,percent of total billed charges,,,769.91,,,percent of total billed charges,,,966.68,,,percent of total billed charges,,,,,,,,,995.28,,,percent of total billed charges,,,995.28,,,percent of total billed charges,,,972.4,,,percent of total billed charges,,,1098.24,,,percent of total billed charges,,,1086.8,,,percent of total billed charges,,,,,,,,,1029.6,,,percent of total billed charges,,,,,,,,,1063.92,,,percent of total billed charges,,,1086.8,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,893.46,,,percent of total billed charges,,,1041.04,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM THYROID W WO FLOW VASCULAR,3413978,CDM,341,RC,78013,CPT,5591,APC,,,,outpatient,facility,,,1144,1144,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM THYROID UPTAKE MEAS W WO FLW STM,3413986,CDM,341,RC,78014,CPT,,,,,,inpatient,facility,,,1430,600.6,1215.5,1372.8,,1215.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1244.1,,,percent of total billed charges,,,,,,,,,1287,,,percent of total billed charges,,,1372.8,,,percent of total billed charges,,,1358.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1329.9,,,percent of total billed charges,,,1358.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM THYROID UPTAKE MEAS W WO FLW STM,3413986,CDM,341,RC,78014,CPT,,,,,,outpatient,facility,,,1430,600.6,386.1,1372.8,,1215.5,,,percent of total billed charges,,,386.1,,,percent of total billed charges,,,983.84,,,percent of total billed charges,,,962.39,,,percent of total billed charges,,,1208.35,,,percent of total billed charges,,,,,,,,,1244.1,,,percent of total billed charges,,,1244.1,,,percent of total billed charges,,,1215.5,,,percent of total billed charges,,,1372.8,,,percent of total billed charges,,,1358.5,,,percent of total billed charges,,,,,,,,,1287,,,percent of total billed charges,,,,,,,,,1329.9,,,percent of total billed charges,,,1358.5,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,1116.83,,,percent of total billed charges,,,1301.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM THYROID UPTAKE MEAS W WO FLW STM,3413986,CDM,341,RC,78014,CPT,5591,APC,,,,outpatient,facility,,,1430,1430,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PLANAR PARATHYROID,3413994,CDM,341,RC,78070,CPT,,,,,,inpatient,facility,,,1037,435.54,881.45,995.52,,881.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,902.19,,,percent of total billed charges,,,,,,,,,933.3,,,percent of total billed charges,,,995.52,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,964.41,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PLANAR PARATHYROID,3413994,CDM,341,RC,78070,CPT,,,,,,outpatient,facility,,,1037,435.54,279.99,995.52,,881.45,,,percent of total billed charges,,,279.99,,,percent of total billed charges,,,713.46,,,percent of total billed charges,,,697.9,,,percent of total billed charges,,,876.26,,,percent of total billed charges,,,,,,,,,902.19,,,percent of total billed charges,,,902.19,,,percent of total billed charges,,,881.45,,,percent of total billed charges,,,995.52,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,933.3,,,percent of total billed charges,,,,,,,,,964.41,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,809.9,,,percent of total billed charges,,,943.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PLANAR PARATHYROID,3413994,CDM,341,RC,78070,CPT,5591,APC,,,,outpatient,facility,,,1037,1037,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PLANAR PARATHYROID W SPECT,3414000,CDM,341,RC,78071,CPT,,,,,,inpatient,facility,,,1037,435.54,881.45,995.52,,881.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,902.19,,,percent of total billed charges,,,,,,,,,933.3,,,percent of total billed charges,,,995.52,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,964.41,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PLANAR PARATHYROID W SPECT,3414000,CDM,341,RC,78071,CPT,,,,,,outpatient,facility,,,1037,435.54,279.99,995.52,,881.45,,,percent of total billed charges,,,279.99,,,percent of total billed charges,,,713.46,,,percent of total billed charges,,,697.9,,,percent of total billed charges,,,876.26,,,percent of total billed charges,,,,,,,,,902.19,,,percent of total billed charges,,,902.19,,,percent of total billed charges,,,881.45,,,percent of total billed charges,,,995.52,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,933.3,,,percent of total billed charges,,,,,,,,,964.41,,,percent of total billed charges,,,985.15,,,percent of total billed charges,,,,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,412.45,,,fee schedule,,,,,,,,,809.9,,,percent of total billed charges,,,943.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PLANAR PARATHYROID W SPECT,3414000,CDM,341,RC,78071,CPT,5591,APC,,,,outpatient,facility,,,1037,1037,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM PLANAR PARATHYROID W SPECT CT,3414018,CDM,341,RC,78072,CPT,,,,,,inpatient,facility,,,1131,475.02,961.35,1085.76,,961.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,983.97,,,percent of total billed charges,,,,,,,,,1017.9,,,percent of total billed charges,,,1085.76,,,percent of total billed charges,,,1074.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1051.83,,,percent of total billed charges,,,1074.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM PLANAR PARATHYROID W SPECT CT,3414018,CDM,341,RC,78072,CPT,,,,,,outpatient,facility,,,1131,475.02,305.37,1085.76,,961.35,,,percent of total billed charges,,,305.37,,,percent of total billed charges,,,778.13,,,percent of total billed charges,,,761.16,,,percent of total billed charges,,,955.69,,,percent of total billed charges,,,,,,,,,983.97,,,percent of total billed charges,,,983.97,,,percent of total billed charges,,,961.35,,,percent of total billed charges,,,1085.76,,,percent of total billed charges,,,1074.45,,,percent of total billed charges,,,,,,,,,1017.9,,,percent of total billed charges,,,,,,,,,1051.83,,,percent of total billed charges,,,1074.45,,,percent of total billed charges,,,,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,540.52,,,fee schedule,,,,,,,,,883.31,,,percent of total billed charges,,,1029.21,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM PLANAR PARATHYROID W SPECT CT,3414018,CDM,341,RC,78072,CPT,5592,APC,,,,outpatient,facility,,,1131,1131,274.04,799.75,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,562.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,551.55,,,fee schedule,,,,,,,,,,,,,,,799.75,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",744.59,,,fee schedule,,,,,,,,,,,,,,,,,,,,,551.55,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,551.55,,,fee schedule,,,551.55,,,fee schedule,,,274.04,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
RRX DTPA AEROSOL DOSE 0 75MCI,3414067,CDM,343,RC,A9567,HCPCS,,,,,,inpatient,facility,,,581,244.02,493.85,557.76,,493.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,505.47,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX DTPA AEROSOL DOSE 0 75MCI,3414067,CDM,343,RC,A9567,HCPCS,,,,,,outpatient,facility,,,581,244.02,45.11,581,,493.85,,,percent of total billed charges,,,156.87,,,percent of total billed charges,,,399.73,,,percent of total billed charges,,,391.01,,,percent of total billed charges,,,490.94,,,percent of total billed charges,,,,,,,,,505.47,,,percent of total billed charges,,,505.47,,,percent of total billed charges,,,493.85,,,percent of total billed charges,,,557.76,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,522.9,,,percent of total billed charges,,,,,,,,,540.33,,,percent of total billed charges,,,551.95,,,percent of total billed charges,,,,,,,,,,,,,,,581,,,fee schedule,,,581,,,fee schedule,,,581,,,fee schedule,,,,,,,,,45.11,,,percent of total billed charges,,Paid in addition to outpatient services ,528.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
RRX TC 99 TILMANOCEPT 0.5MCI INJ,3414075,CDM,343,RC,A9520,HCPCS,,,,,,inpatient,facility,,,716,300.72,608.6,687.36,,608.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,622.92,,,percent of total billed charges,,,,,,,,,644.4,,,percent of total billed charges,,,687.36,,,percent of total billed charges,,,680.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,665.88,,,percent of total billed charges,,,680.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
RRX TC 99 TILMANOCEPT 0.5MCI INJ,3414075,CDM,343,RC,A9520,HCPCS,,,,,,outpatient,facility,,,716,300.72,193.32,716,,608.6,,,percent of total billed charges,,,193.32,,,percent of total billed charges,,,492.61,,,percent of total billed charges,,,481.87,,,percent of total billed charges,,,605.02,,,percent of total billed charges,,,,,,,,,622.92,,,percent of total billed charges,,,622.92,,,percent of total billed charges,,,608.6,,,percent of total billed charges,,,687.36,,,percent of total billed charges,,,680.2,,,percent of total billed charges,,,,,,,,,644.4,,,percent of total billed charges,,,,,,,,,665.88,,,percent of total billed charges,,,680.2,,,percent of total billed charges,,,,,,,,,,,,,,,716,,,fee schedule,,,716,,,fee schedule,,,716,,,fee schedule,,,,,,,,,,,,,,,651.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR 1 AREA 1D IMG,3414356,CDM,341,RC,78800,CPT,,,,,,inpatient,facility,,,1227,515.34,1042.95,1177.92,,1042.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1067.49,,,percent of total billed charges,,,,,,,,,1104.3,,,percent of total billed charges,,,1177.92,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1141.11,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR 1 AREA 1D IMG,3414356,CDM,341,RC,78800,CPT,,,,,,outpatient,facility,,,1227,515.34,331.29,1227,,1042.95,,,percent of total billed charges,,,331.29,,,percent of total billed charges,,,844.18,,,percent of total billed charges,,,825.77,,,percent of total billed charges,,,1036.82,,,percent of total billed charges,,,,,,,,,1067.49,,,percent of total billed charges,,,1067.49,,,percent of total billed charges,,,1042.95,,,percent of total billed charges,,,1177.92,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,1104.3,,,percent of total billed charges,,,,,,,,,1141.11,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,,,,,,,1227,,,fee schedule,,,1227,,,fee schedule,,,1227,,,fee schedule,,,,,,,,,958.29,,,percent of total billed charges,,,1116.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR 1 AREA 1D IMG,3414356,CDM,341,RC,78800,CPT,5591,APC,,,,outpatient,facility,,,1227,1227,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOC RRX TMR PLNR 2 PLUSAREA 1 PLUSD IMG,3414364,CDM,341,RC,78801,CPT,,,,,,inpatient,facility,,,1227,515.34,1042.95,1177.92,,1042.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1067.49,,,percent of total billed charges,,,,,,,,,1104.3,,,percent of total billed charges,,,1177.92,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1141.11,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR 2 PLUSAREA 1 PLUSD IMG,3414364,CDM,341,RC,78801,CPT,,,,,,outpatient,facility,,,1227,515.34,331.29,1227,,1042.95,,,percent of total billed charges,,,331.29,,,percent of total billed charges,,,844.18,,,percent of total billed charges,,,825.77,,,percent of total billed charges,,,1036.82,,,percent of total billed charges,,,,,,,,,1067.49,,,percent of total billed charges,,,1067.49,,,percent of total billed charges,,,1042.95,,,percent of total billed charges,,,1177.92,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,1104.3,,,percent of total billed charges,,,,,,,,,1141.11,,,percent of total billed charges,,,1165.65,,,percent of total billed charges,,,,,,,,,,,,,,,1227,,,fee schedule,,,1227,,,fee schedule,,,1227,,,fee schedule,,,,,,,,,958.29,,,percent of total billed charges,,,1116.57,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR PLNR 2 PLUSAREA 1 PLUSD IMG,3414364,CDM,341,RC,78801,CPT,5591,APC,,,,outpatient,facility,,,1227,1227,211.13,610.26,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,429.29,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,420.87,,,fee schedule,,,,,,,,,,,,,,,610.26,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",568.17,,,fee schedule,,,,,,,,,,,,,,,,,,,,,420.87,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,420.87,,,fee schedule,,,420.87,,,fee schedule,,,211.13,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOC RRX TMR SPECT 1AREA 1ACQ 1D,3414372,CDM,341,RC,78803,CPT,,,,,,inpatient,facility,,,2806,1178.52,2385.1,2693.76,,2385.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2441.22,,,percent of total billed charges,,,,,,,,,2525.4,,,percent of total billed charges,,,2693.76,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2609.58,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT 1AREA 1ACQ 1D,3414372,CDM,341,RC,78803,CPT,,,,,,outpatient,facility,,,2806,1178.52,757.62,2693.76,,2385.1,,,percent of total billed charges,,,757.62,,,percent of total billed charges,,,1930.53,,,percent of total billed charges,,,1888.44,,,percent of total billed charges,,,2371.07,,,percent of total billed charges,,,,,,,,,2441.22,,,percent of total billed charges,,,2441.22,,,percent of total billed charges,,,2385.1,,,percent of total billed charges,,,2693.76,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,2525.4,,,percent of total billed charges,,,,,,,,,2609.58,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,2191.49,,,percent of total billed charges,,,2553.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT 1AREA 1ACQ 1D,3414372,CDM,341,RC,78803,CPT,5593,APC,,,,outpatient,facility,,,2806,2806,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOC RRX TMR SPECT CT 1AREA 1ACQ,3414380,CDM,341,RC,78830,CPT,,,,,,inpatient,facility,,,2906,1220.52,2470.1,2789.76,,2470.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2528.22,,,percent of total billed charges,,,,,,,,,2615.4,,,percent of total billed charges,,,2789.76,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2702.58,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT CT 1AREA 1ACQ,3414380,CDM,341,RC,78830,CPT,,,,,,outpatient,facility,,,2906,1220.52,784.62,2789.76,,2470.1,,,percent of total billed charges,,,784.62,,,percent of total billed charges,,,1999.33,,,percent of total billed charges,,,1955.74,,,percent of total billed charges,,,2455.57,,,percent of total billed charges,,,,,,,,,2528.22,,,percent of total billed charges,,,2528.22,,,percent of total billed charges,,,2470.1,,,percent of total billed charges,,,2789.76,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,2615.4,,,percent of total billed charges,,,,,,,,,2702.58,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,2269.59,,,percent of total billed charges,,,2644.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT CT 1AREA 1ACQ,3414380,CDM,341,RC,78830,CPT,5593,APC,,,,outpatient,facility,,,2906,2906,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOC RRX TMR SPECT 2 PLUSAREA 2ACQ,3414398,CDM,341,RC,78831,CPT,,,,,,inpatient,facility,,,2806,1178.52,2385.1,2693.76,,2385.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2441.22,,,percent of total billed charges,,,,,,,,,2525.4,,,percent of total billed charges,,,2693.76,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2609.58,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT 2 PLUSAREA 2ACQ,3414398,CDM,341,RC,78831,CPT,,,,,,outpatient,facility,,,2806,1178.52,757.62,2693.76,,2385.1,,,percent of total billed charges,,,757.62,,,percent of total billed charges,,,1930.53,,,percent of total billed charges,,,1888.44,,,percent of total billed charges,,,2371.07,,,percent of total billed charges,,,,,,,,,2441.22,,,percent of total billed charges,,,2441.22,,,percent of total billed charges,,,2385.1,,,percent of total billed charges,,,2693.76,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,2525.4,,,percent of total billed charges,,,,,,,,,2609.58,,,percent of total billed charges,,,2665.7,,,percent of total billed charges,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,1420.01,,,fee schedule,,,,,,,,,2191.49,,,percent of total billed charges,,,2553.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT 2 PLUSAREA 2ACQ,3414398,CDM,341,RC,78831,CPT,5593,APC,,,,outpatient,facility,,,2806,2806,720.98,2101.04,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1477.97,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1448.99,,,fee schedule,,,,,,,,,,,,,,,2101.04,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",1956.14,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1448.99,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1448.99,,,fee schedule,,,1448.99,,,fee schedule,,,720.98,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
NM LOC RRX TMR SPECT CT 2 PLUSAREA 2ACQ,3414406,CDM,341,RC,78832,CPT,,,,,,inpatient,facility,,,2906,1220.52,2470.1,2789.76,,2470.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,2528.22,,,percent of total billed charges,,,,,,,,,2615.4,,,percent of total billed charges,,,2789.76,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,2702.58,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT CT 2 PLUSAREA 2ACQ,3414406,CDM,341,RC,78832,CPT,,,,,,outpatient,facility,,,2906,1220.52,784.62,2789.76,,2470.1,,,percent of total billed charges,,,784.62,,,percent of total billed charges,,,1999.33,,,percent of total billed charges,,,1955.74,,,percent of total billed charges,,,2455.57,,,percent of total billed charges,,,,,,,,,2528.22,,,percent of total billed charges,,,2528.22,,,percent of total billed charges,,,2470.1,,,percent of total billed charges,,,2789.76,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,2615.4,,,percent of total billed charges,,,,,,,,,2702.58,,,percent of total billed charges,,,2760.7,,,percent of total billed charges,,,,,,,,,,,,,,,1596.43,,,fee schedule,,,1596.43,,,fee schedule,,,1564.5,,,fee schedule,,,,,,,,,2269.59,,,percent of total billed charges,,,2644.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
NM LOC RRX TMR SPECT CT 2 PLUSAREA 2ACQ,3414406,CDM,341,RC,78832,CPT,5594,APC,,,,outpatient,facility,,,2906,2906,809.02,2314.82,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1596.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1628.36,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1596.43,,,fee schedule,,,,,,,,,,,,,,,2314.82,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2155.18,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1596.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1596.43,,,fee schedule,,,1596.43,,,fee schedule,,,809.02,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
AUG SACRAL PERC INJ UNI,3502515,CDM,361,RC,0200T,CPT,,,,,,inpatient,facility,,,5506,2312.52,4680.1,5285.76,,4680.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,4790.22,,,percent of total billed charges,,,,,,,,,4955.4,,,percent of total billed charges,,,5285.76,,,percent of total billed charges,,,5230.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,5120.58,,,percent of total billed charges,,,5230.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
AUG SACRAL PERC INJ UNI,3502515,CDM,361,RC,0200T,CPT,,,,,,outpatient,facility,,,5506,2312.52,1486.62,15487,,4680.1,,,percent of total billed charges,,,1486.62,,,percent of total billed charges,,,3788.13,,,percent of total billed charges,,,3705.54,,,percent of total billed charges,,,4652.57,,,percent of total billed charges,,,,,,,,,4790.22,,,percent of total billed charges,,,4790.22,,,percent of total billed charges,,,4680.1,,,percent of total billed charges,,,5285.76,,,percent of total billed charges,,,5230.7,,,percent of total billed charges,,,,,,,,,4955.4,,,percent of total billed charges,,,,,,,,,5120.58,,,percent of total billed charges,,,5230.7,,,percent of total billed charges,,,,,,,,,,,,,,,5506,,,fee schedule,,,5506,,,fee schedule,,,5506,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,5010.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
AUG SACRAL PERC INJ UNI,3502515,CDM,361,RC,0200T,CPT,5114,APC,,,,outpatient,facility,,,5506,5506,3593.08,10585.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7300.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7446.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,7300.29,,,fee schedule,,,,,,,,,,,,,,,10585.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9855.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7300.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,7300.29,,,fee schedule,,,7300.29,,,fee schedule,,,3593.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
AUG SACRAL PERC INJ BI,3502523,CDM,361,RC,0201T,CPT,,,,,,inpatient,facility,,,12326,5176.92,10477.1,11832.96,,10477.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,10723.62,,,percent of total billed charges,,,,,,,,,11093.4,,,percent of total billed charges,,,11832.96,,,percent of total billed charges,,,11709.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11463.18,,,percent of total billed charges,,,11709.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
AUG SACRAL PERC INJ BI,3502523,CDM,361,RC,0201T,CPT,,,,,,outpatient,facility,,,12326,5176.92,3328.02,15487,,10477.1,,,percent of total billed charges,,,3328.02,,,percent of total billed charges,,,8480.29,,,percent of total billed charges,,,8295.4,,,percent of total billed charges,,,10415.47,,,percent of total billed charges,,,,,,,,,10723.62,,,percent of total billed charges,,,10723.62,,,percent of total billed charges,,,10477.1,,,percent of total billed charges,,,11832.96,,,percent of total billed charges,,,11709.7,,,percent of total billed charges,,,,,,,,,11093.4,,,percent of total billed charges,,,,,,,,,11463.18,,,percent of total billed charges,,,11709.7,,,percent of total billed charges,,,,,,,,,,,,,,,12326,,,fee schedule,,,12326,,,fee schedule,,,12326,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,11216.66,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
AUG SACRAL PERC INJ BI,3502523,CDM,361,RC,0201T,CPT,5114,APC,,,,outpatient,facility,,,12326,12326,3593.08,10585.42,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7300.29,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,7446.3,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,7300.29,,,fee schedule,,,,,,,,,,,,,,,10585.42,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",9855.39,,,fee schedule,,,,,,,,,,,,,,,,,,,,,7300.29,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,7300.29,,,fee schedule,,,7300.29,,,fee schedule,,,3593.08,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ABL RF TUMOR S BONE PERC IMG GD,3502622,CDM,361,RC,20982,CPT,,,,,,inpatient,facility,,,12822,5385.24,10898.7,12309.12,,10898.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,11155.14,,,percent of total billed charges,,,,,,,,,11539.8,,,percent of total billed charges,,,12309.12,,,percent of total billed charges,,,12180.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,11924.46,,,percent of total billed charges,,,12180.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ABL RF TUMOR S BONE PERC IMG GD,3502622,CDM,361,RC,20982,CPT,,,,,,outpatient,facility,,,12822,5385.24,3461.94,19860,,10898.7,,,percent of total billed charges,,,3461.94,,,percent of total billed charges,,,8821.54,,,percent of total billed charges,,,8629.21,,,percent of total billed charges,,,10834.59,,,percent of total billed charges,,,,,,,,,11155.14,,,percent of total billed charges,,,11155.14,,,percent of total billed charges,,,10898.7,,,percent of total billed charges,,,12309.12,,,percent of total billed charges,,,12180.9,,,percent of total billed charges,,,,,,,,,11539.8,,,percent of total billed charges,,,,,,,,,11924.46,,,percent of total billed charges,,,12180.9,,,percent of total billed charges,,,,,,,,,,,,,,,13430.15,,,fee schedule,,,13430.15,,,fee schedule,,,13161.55,,,fee schedule,,,,,,,,,19860,,,percent of total billed charges,,,11668.02,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ABL RF TUMOR S BONE PERC IMG GD,3502622,CDM,361,RC,20982,CPT,5115,APC,,,,outpatient,facility,,,12822,12822,7087.75,19473.72,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13430.15,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,13698.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,13430.15,,,fee schedule,,,,,,,,,,,,,,,19473.72,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",18130.7,,,fee schedule,,,,,,,,,,,,,,,,,,,,,13430.15,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,13430.15,,,fee schedule,,,13430.15,,,fee schedule,,,7087.75,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
VERTEBROPLASTY CRVTHOR PERC,3502648,CDM,361,RC,22510,CPT,,,,,,inpatient,facility,,,7298,3065.16,6203.3,7006.08,,6203.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6349.26,,,percent of total billed charges,,,,,,,,,6568.2,,,percent of total billed charges,,,7006.08,,,percent of total billed charges,,,6933.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,6787.14,,,percent of total billed charges,,,6933.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
VERTEBROPLASTY CRVTHOR PERC,3502648,CDM,361,RC,22510,CPT,,,,,,outpatient,facility,,,7298,3065.16,1970.46,15487,,6203.3,,,percent of total billed charges,,,1970.46,,,percent of total billed charges,,,5021.02,,,percent of total billed charges,,,4911.55,,,percent of total billed charges,,,6166.81,,,percent of total billed charges,,,,,,,,,6349.26,,,percent of total billed charges,,,6349.26,,,percent of total billed charges,,,6203.3,,,percent of total billed charges,,,7006.08,,,percent of total billed charges,,,6933.1,,,percent of total billed charges,,,,,,,,,6568.2,,,percent of total billed charges,,,,,,,,,6787.14,,,percent of total billed charges,,,6933.1,,,percent of total billed charges,,,,,,,,,,,,,,,3303,,,fee schedule,,,3303,,,fee schedule,,,3236.94,,,fee schedule,,,,,,,,,15487,,,percent of total billed charges,,,6641.18,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
VERTEBROPLASTY CRVTHOR PERC,3502648,CDM,361,RC,22510,CPT,5113,APC,,,,outpatient,facility,,,7298,7298,1616.93,4789.35,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3303,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,3369.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,3303,,,fee schedule,,,,,,,,,,,,,,,4789.35,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",4459.05,,,fee schedule,,,,,,,,,,,,,,,,,,,,,3303,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,3303,,,fee schedule,,,3303,,,fee schedule,,,1616.93,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
ABL RF TUMOR S LIVER PERC,3521903,CDM,361,RC,47382,CPT,,,,,,inpatient,facility,,,10632,4465.44,9037.2,10206.72,,9037.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,9249.84,,,percent of total billed charges,,,,,,,,,9568.8,,,percent of total billed charges,,,10206.72,,,percent of total billed charges,,,10100.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,9887.76,,,percent of total billed charges,,,10100.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
ABL RF TUMOR S LIVER PERC,3521903,CDM,361,RC,47382,CPT,,,,,,outpatient,facility,,,10632,4465.44,2870.64,28046,,9037.2,,,percent of total billed charges,,,2870.64,,,percent of total billed charges,,,7314.82,,,percent of total billed charges,,,7155.34,,,percent of total billed charges,,,8984.04,,,percent of total billed charges,,,,,,,,,9249.84,,,percent of total billed charges,,,9249.84,,,percent of total billed charges,,,9037.2,,,percent of total billed charges,,,10206.72,,,percent of total billed charges,,,10100.4,,,percent of total billed charges,,,,,,,,,9568.8,,,percent of total billed charges,,,,,,,,,9887.76,,,percent of total billed charges,,,10100.4,,,percent of total billed charges,,,,,,,,,,,,,,,5887.92,,,fee schedule,,,5887.92,,,fee schedule,,,5770.16,,,fee schedule,,,,,,,,,28046,,,percent of total billed charges,,,9675.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
ABL RF TUMOR S LIVER PERC,3521903,CDM,361,RC,47382,CPT,5361,APC,,,,outpatient,facility,,,10632,10632,2831.25,8537.48,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,6005.68,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,5887.92,,,fee schedule,,,,,,,,,,,,,,,8537.48,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",7948.69,,,fee schedule,,,,,,,,,,,,,,,,,,,,,5887.92,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,5887.92,,,fee schedule,,,5887.92,,,fee schedule,,,2831.25,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
BX PLEURA NDL PERC,3522133,CDM,361,RC,32400,CPT,,,,,,inpatient,facility,,,1899,797.58,1614.15,1823.04,,1614.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1652.13,,,percent of total billed charges,,,,,,,,,1709.1,,,percent of total billed charges,,,1823.04,,,percent of total billed charges,,,1804.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1766.07,,,percent of total billed charges,,,1804.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
BX PLEURA NDL PERC,3522133,CDM,361,RC,32400,CPT,,,,,,outpatient,facility,,,1899,797.58,512.73,5933,,1614.15,,,percent of total billed charges,,,512.73,,,percent of total billed charges,,,1306.51,,,percent of total billed charges,,,1278.03,,,percent of total billed charges,,,1604.65,,,percent of total billed charges,,,,,,,,,1652.13,,,percent of total billed charges,,,1652.13,,,percent of total billed charges,,,1614.15,,,percent of total billed charges,,,1823.04,,,percent of total billed charges,,,1804.05,,,percent of total billed charges,,,,,,,,,1709.1,,,percent of total billed charges,,,,,,,,,1766.07,,,percent of total billed charges,,,1804.05,,,percent of total billed charges,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,1621.34,,,fee schedule,,,,,,,,,5933,,,percent of total billed charges,,,1728.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
BX PLEURA NDL PERC,3522133,CDM,361,RC,32400,CPT,5072,APC,,,,outpatient,facility,,,1899,1899,814.56,2398.92,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1687.52,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,1654.43,,,fee schedule,,,,,,,,,,,,,,,2398.92,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",2233.48,,,fee schedule,,,,,,,,,,,,,,,,,,,,,1654.43,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,1654.43,,,fee schedule,,,1654.43,,,fee schedule,,,814.56,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT LTD FOLLOWUP,3522182,CDM,350,RC,76380,CPT,,,,,,inpatient,facility,,,585,245.7,497.25,561.6,,497.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,508.95,,,percent of total billed charges,,,,,,,,,526.5,,,percent of total billed charges,,,561.6,,,percent of total billed charges,,,555.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,544.05,,,percent of total billed charges,,,555.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT LTD FOLLOWUP,3522182,CDM,350,RC,76380,CPT,,,,,,outpatient,facility,,,585,245.7,90.88,561.6,,497.25,,,percent of total billed charges,,,157.95,,,percent of total billed charges,,,402.48,,,percent of total billed charges,,,393.7,,,percent of total billed charges,,,494.32,,,percent of total billed charges,,,,,,,,,508.95,,,percent of total billed charges,,,508.95,,,percent of total billed charges,,,497.25,,,percent of total billed charges,,,561.6,,,percent of total billed charges,,,555.75,,,percent of total billed charges,,,,,,,,,526.5,,,percent of total billed charges,,,,,,,,,544.05,,,percent of total billed charges,,,555.75,,,percent of total billed charges,,,,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,90.88,,,fee schedule,,,,,,,,,456.88,,,percent of total billed charges,,,532.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT LTD FOLLOWUP,3522182,CDM,350,RC,76380,CPT,5521,APC,,,,outpatient,facility,,,585,585,47.19,134.46,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,94.58,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,92.73,,,fee schedule,,,,,,,,,,,,,,,134.46,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",125.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,92.73,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,92.73,,,fee schedule,,,92.73,,,fee schedule,,,47.19,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT GD PLCMT FIELDS THRPY RAD,3522190,CDM,350,RC,77014,CPT,,,,,,inpatient,facility,,,1092,458.64,928.2,1048.32,,928.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,950.04,,,percent of total billed charges,,,,,,,,,982.8,,,percent of total billed charges,,,1048.32,,,percent of total billed charges,,,1037.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1015.56,,,percent of total billed charges,,,1037.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT GD PLCMT FIELDS THRPY RAD,3522190,CDM,350,RC,77014,CPT,,,,,,outpatient,facility,,,1092,458.64,294.84,1092,,928.2,,,percent of total billed charges,,,294.84,,,percent of total billed charges,,,751.3,,,percent of total billed charges,,,734.92,,,percent of total billed charges,,,922.74,,,percent of total billed charges,,,,,,,,,950.04,,,percent of total billed charges,,,950.04,,,percent of total billed charges,,,928.2,,,percent of total billed charges,,,1048.32,,,percent of total billed charges,,,1037.4,,,percent of total billed charges,,,,,,,,,982.8,,,percent of total billed charges,,,,,,,,,1015.56,,,percent of total billed charges,,,1037.4,,,percent of total billed charges,,,,,,,,,,,,,,,1092,,,fee schedule,,,1092,,,fee schedule,,,1092,,,fee schedule,,,,,,,,,852.85,,,percent of total billed charges,,,993.72,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT GD ABLATION TISSUE,3522208,CDM,350,RC,77013,CPT,,,,,,inpatient,facility,,,1532,643.44,1302.2,1470.72,,1302.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1332.84,,,percent of total billed charges,,,,,,,,,1378.8,,,percent of total billed charges,,,1470.72,,,percent of total billed charges,,,1455.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1424.76,,,percent of total billed charges,,,1455.4,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT GD ABLATION TISSUE,3522208,CDM,350,RC,77013,CPT,,,,,,outpatient,facility,,,1532,643.44,413.64,1532,,1302.2,,,percent of total billed charges,,,413.64,,,percent of total billed charges,,,1054.02,,,percent of total billed charges,,,1031.04,,,percent of total billed charges,,,1294.54,,,percent of total billed charges,,,,,,,,,1332.84,,,percent of total billed charges,,,1332.84,,,percent of total billed charges,,,1302.2,,,percent of total billed charges,,,1470.72,,,percent of total billed charges,,,1455.4,,,percent of total billed charges,,,,,,,,,1378.8,,,percent of total billed charges,,,,,,,,,1424.76,,,percent of total billed charges,,,1455.4,,,percent of total billed charges,,,,,,,,,,,,,,,1532,,,fee schedule,,,1532,,,fee schedule,,,1532,,,fee schedule,,,,,,,,,1196.49,,,percent of total billed charges,,,1394.12,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT GD LOC STEREOTACTIC,3522224,CDM,350,RC,77011,CPT,,,,,,inpatient,facility,,,1795,753.9,1525.75,1723.2,,1525.75,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1561.65,,,percent of total billed charges,,,,,,,,,1615.5,,,percent of total billed charges,,,1723.2,,,percent of total billed charges,,,1705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1669.35,,,percent of total billed charges,,,1705.25,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT GD LOC STEREOTACTIC,3522224,CDM,350,RC,77011,CPT,,,,,,outpatient,facility,,,1795,753.9,484.65,1795,,1525.75,,,percent of total billed charges,,,484.65,,,percent of total billed charges,,,1234.96,,,percent of total billed charges,,,1208.03,,,percent of total billed charges,,,1516.77,,,percent of total billed charges,,,,,,,,,1561.65,,,percent of total billed charges,,,1561.65,,,percent of total billed charges,,,1525.75,,,percent of total billed charges,,,1723.2,,,percent of total billed charges,,,1705.25,,,percent of total billed charges,,,,,,,,,1615.5,,,percent of total billed charges,,,,,,,,,1669.35,,,percent of total billed charges,,,1705.25,,,percent of total billed charges,,,,,,,,,,,,,,,1795,,,fee schedule,,,1795,,,fee schedule,,,1795,,,fee schedule,,,,,,,,,1401.89,,,percent of total billed charges,,,1633.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT GD W PLC CATH DRN PERC S ANDI,3522240,CDM,350,RC,75989,CPT,,,,,,inpatient,facility,,,1949,818.58,1656.65,1871.04,,1656.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1695.63,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT GD W PLC CATH DRN PERC S ANDI,3522240,CDM,350,RC,75989,CPT,,,,,,outpatient,facility,,,1949,818.58,526.23,1949,,1656.65,,,percent of total billed charges,,,526.23,,,percent of total billed charges,,,1340.91,,,percent of total billed charges,,,1311.68,,,percent of total billed charges,,,1646.9,,,percent of total billed charges,,,,,,,,,1695.63,,,percent of total billed charges,,,1695.63,,,percent of total billed charges,,,1656.65,,,percent of total billed charges,,,1871.04,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,1754.1,,,percent of total billed charges,,,,,,,,,1812.57,,,percent of total billed charges,,,1851.55,,,percent of total billed charges,,,,,,,,,,,,,,,1949,,,fee schedule,,,1949,,,fee schedule,,,1949,,,fee schedule,,,,,,,,,1522.17,,,percent of total billed charges,,,1773.59,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT ANALYSIS PERFUSION CEREBRAL,3522265,CDM,350,RC,0042T,CPT,,,,,,inpatient,facility,,,1289,541.38,1095.65,1237.44,,1095.65,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1121.43,,,percent of total billed charges,,,,,,,,,1160.1,,,percent of total billed charges,,,1237.44,,,percent of total billed charges,,,1224.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1198.77,,,percent of total billed charges,,,1224.55,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT ANALYSIS PERFUSION CEREBRAL,3522265,CDM,350,RC,0042T,CPT,,,,,,outpatient,facility,,,1289,541.38,348.03,1289,,1095.65,,,percent of total billed charges,,,348.03,,,percent of total billed charges,,,886.83,,,percent of total billed charges,,,867.5,,,percent of total billed charges,,,1089.2,,,percent of total billed charges,,,,,,,,,1121.43,,,percent of total billed charges,,,1121.43,,,percent of total billed charges,,,1095.65,,,percent of total billed charges,,,1237.44,,,percent of total billed charges,,,1224.55,,,percent of total billed charges,,,,,,,,,1160.1,,,percent of total billed charges,,,,,,,,,1198.77,,,percent of total billed charges,,,1224.55,,,percent of total billed charges,,,,,,,,,,,,,,,1289,,,fee schedule,,,1289,,,fee schedule,,,1289,,,fee schedule,,,,,,,,,1006.71,,,percent of total billed charges,,,1172.99,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CTA AORTA ABD RUNOFF W CNT,3522307,CDM,350,RC,75635,CPT,,,,,,inpatient,facility,,,1306,548.52,1110.1,1253.76,,1110.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1136.22,,,percent of total billed charges,,,,,,,,,1175.4,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CTA AORTA ABD RUNOFF W CNT,3522307,CDM,350,RC,75635,CPT,,,,,,outpatient,facility,,,1306,548.52,183.74,1253.76,,1110.1,,,percent of total billed charges,,,352.62,,,percent of total billed charges,,,898.53,,,percent of total billed charges,,,878.94,,,percent of total billed charges,,,1103.57,,,percent of total billed charges,,,,,,,,,1136.22,,,percent of total billed charges,,,1136.22,,,percent of total billed charges,,,1110.1,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,1175.4,,,percent of total billed charges,,,,,,,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1019.99,,,percent of total billed charges,,,1188.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CTA AORTA ABD RUNOFF W CNT,3522307,CDM,350,RC,75635,CPT,5571,APC,,,,outpatient,facility,,,1306,1306,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT HEAD W CNT,3522687,CDM,351,RC,70460,CPT,,,,,,inpatient,facility,,,1291,542.22,1097.35,1239.36,,1097.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1123.17,,,percent of total billed charges,,,,,,,,,1161.9,,,percent of total billed charges,,,1239.36,,,percent of total billed charges,,,1226.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1200.63,,,percent of total billed charges,,,1226.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT HEAD W CNT,3522687,CDM,351,RC,70460,CPT,,,,,,outpatient,facility,,,1291,542.22,183.74,1239.36,,1097.35,,,percent of total billed charges,,,348.57,,,percent of total billed charges,,,888.21,,,percent of total billed charges,,,868.84,,,percent of total billed charges,,,1090.89,,,percent of total billed charges,,,,,,,,,1123.17,,,percent of total billed charges,,,1123.17,,,percent of total billed charges,,,1097.35,,,percent of total billed charges,,,1239.36,,,percent of total billed charges,,,1226.45,,,percent of total billed charges,,,,,,,,,1161.9,,,percent of total billed charges,,,,,,,,,1200.63,,,percent of total billed charges,,,1226.45,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1008.27,,,percent of total billed charges,,,1174.81,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT HEAD W CNT,3522687,CDM,351,RC,70460,CPT,5571,APC,,,,outpatient,facility,,,1291,1291,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT HEAD WO CNT,3522695,CDM,351,RC,70450,CPT,,,,,,inpatient,facility,,,916,384.72,778.6,879.36,,778.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,796.92,,,percent of total billed charges,,,,,,,,,824.4,,,percent of total billed charges,,,879.36,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,851.88,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT HEAD WO CNT,3522695,CDM,351,RC,70450,CPT,,,,,,outpatient,facility,,,916,384.72,109.95,879.36,,778.6,,,percent of total billed charges,,,247.32,,,percent of total billed charges,,,630.21,,,percent of total billed charges,,,616.47,,,percent of total billed charges,,,774.02,,,percent of total billed charges,,,,,,,,,796.92,,,percent of total billed charges,,,796.92,,,percent of total billed charges,,,778.6,,,percent of total billed charges,,,879.36,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,824.4,,,percent of total billed charges,,,,,,,,,851.88,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,715.4,,,percent of total billed charges,,,833.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT HEAD WO CNT,3522695,CDM,351,RC,70450,CPT,5522,APC,,,,outpatient,facility,,,916,916,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT HEAD W ANDWO CNT,3522703,CDM,351,RC,70470,CPT,,,,,,inpatient,facility,,,1520,638.4,1292,1459.2,,1292,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1322.4,,,percent of total billed charges,,,,,,,,,1368,,,percent of total billed charges,,,1459.2,,,percent of total billed charges,,,1444,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1413.6,,,percent of total billed charges,,,1444,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT HEAD W ANDWO CNT,3522703,CDM,351,RC,70470,CPT,,,,,,outpatient,facility,,,1520,638.4,183.74,1459.2,,1292,,,percent of total billed charges,,,410.4,,,percent of total billed charges,,,1045.76,,,percent of total billed charges,,,1022.96,,,percent of total billed charges,,,1284.4,,,percent of total billed charges,,,,,,,,,1322.4,,,percent of total billed charges,,,1322.4,,,percent of total billed charges,,,1292,,,percent of total billed charges,,,1459.2,,,percent of total billed charges,,,1444,,,percent of total billed charges,,,,,,,,,1368,,,percent of total billed charges,,,,,,,,,1413.6,,,percent of total billed charges,,,1444,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1187.12,,,percent of total billed charges,,,1383.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT HEAD W ANDWO CNT,3522703,CDM,351,RC,70470,CPT,5571,APC,,,,outpatient,facility,,,1520,1520,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT MAXFACIAL WO CNT,3522711,CDM,351,RC,70486,CPT,,,,,,inpatient,facility,,,916,384.72,778.6,879.36,,778.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,796.92,,,percent of total billed charges,,,,,,,,,824.4,,,percent of total billed charges,,,879.36,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,851.88,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT MAXFACIAL WO CNT,3522711,CDM,351,RC,70486,CPT,,,,,,outpatient,facility,,,916,384.72,109.95,879.36,,778.6,,,percent of total billed charges,,,247.32,,,percent of total billed charges,,,630.21,,,percent of total billed charges,,,616.47,,,percent of total billed charges,,,774.02,,,percent of total billed charges,,,,,,,,,796.92,,,percent of total billed charges,,,796.92,,,percent of total billed charges,,,778.6,,,percent of total billed charges,,,879.36,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,824.4,,,percent of total billed charges,,,,,,,,,851.88,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,715.4,,,percent of total billed charges,,,833.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT MAXFACIAL WO CNT,3522711,CDM,351,RC,70486,CPT,5522,APC,,,,outpatient,facility,,,916,916,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT MAXFACIAL W CNT,3522729,CDM,351,RC,70487,CPT,,,,,,inpatient,facility,,,1099,461.58,934.15,1055.04,,934.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,956.13,,,percent of total billed charges,,,,,,,,,989.1,,,percent of total billed charges,,,1055.04,,,percent of total billed charges,,,1044.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1022.07,,,percent of total billed charges,,,1044.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT MAXFACIAL W CNT,3522729,CDM,351,RC,70487,CPT,,,,,,outpatient,facility,,,1099,461.58,183.74,1055.04,,934.15,,,percent of total billed charges,,,296.73,,,percent of total billed charges,,,756.11,,,percent of total billed charges,,,739.63,,,percent of total billed charges,,,928.65,,,percent of total billed charges,,,,,,,,,956.13,,,percent of total billed charges,,,956.13,,,percent of total billed charges,,,934.15,,,percent of total billed charges,,,1055.04,,,percent of total billed charges,,,1044.05,,,percent of total billed charges,,,,,,,,,989.1,,,percent of total billed charges,,,,,,,,,1022.07,,,percent of total billed charges,,,1044.05,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,858.32,,,percent of total billed charges,,,1000.09,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT MAXFACIAL W CNT,3522729,CDM,351,RC,70487,CPT,5571,APC,,,,outpatient,facility,,,1099,1099,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT MAXFACIAL W ANDWO CNT,3522737,CDM,351,RC,70488,CPT,,,,,,inpatient,facility,,,1337,561.54,1136.45,1283.52,,1136.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1163.19,,,percent of total billed charges,,,,,,,,,1203.3,,,percent of total billed charges,,,1283.52,,,percent of total billed charges,,,1270.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1243.41,,,percent of total billed charges,,,1270.15,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT MAXFACIAL W ANDWO CNT,3522737,CDM,351,RC,70488,CPT,,,,,,outpatient,facility,,,1337,561.54,183.74,1283.52,,1136.45,,,percent of total billed charges,,,360.99,,,percent of total billed charges,,,919.86,,,percent of total billed charges,,,899.8,,,percent of total billed charges,,,1129.76,,,percent of total billed charges,,,,,,,,,1163.19,,,percent of total billed charges,,,1163.19,,,percent of total billed charges,,,1136.45,,,percent of total billed charges,,,1283.52,,,percent of total billed charges,,,1270.15,,,percent of total billed charges,,,,,,,,,1203.3,,,percent of total billed charges,,,,,,,,,1243.41,,,percent of total billed charges,,,1270.15,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1044.2,,,percent of total billed charges,,,1216.67,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT MAXFACIAL W ANDWO CNT,3522737,CDM,351,RC,70488,CPT,5571,APC,,,,outpatient,facility,,,1337,1337,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT NECK ST W CNT,3522745,CDM,351,RC,70491,CPT,,,,,,inpatient,facility,,,1133,475.86,963.05,1087.68,,963.05,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,985.71,,,percent of total billed charges,,,,,,,,,1019.7,,,percent of total billed charges,,,1087.68,,,percent of total billed charges,,,1076.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1053.69,,,percent of total billed charges,,,1076.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT NECK ST W CNT,3522745,CDM,351,RC,70491,CPT,,,,,,outpatient,facility,,,1133,475.86,183.74,1087.68,,963.05,,,percent of total billed charges,,,305.91,,,percent of total billed charges,,,779.5,,,percent of total billed charges,,,762.51,,,percent of total billed charges,,,957.38,,,percent of total billed charges,,,,,,,,,985.71,,,percent of total billed charges,,,985.71,,,percent of total billed charges,,,963.05,,,percent of total billed charges,,,1087.68,,,percent of total billed charges,,,1076.35,,,percent of total billed charges,,,,,,,,,1019.7,,,percent of total billed charges,,,,,,,,,1053.69,,,percent of total billed charges,,,1076.35,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,884.87,,,percent of total billed charges,,,1031.03,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT NECK ST W CNT,3522745,CDM,351,RC,70491,CPT,5571,APC,,,,outpatient,facility,,,1133,1133,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT NECK ST WO CNT,3522752,CDM,351,RC,70490,CPT,,,,,,inpatient,facility,,,918,385.56,780.3,881.28,,780.3,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,798.66,,,percent of total billed charges,,,,,,,,,826.2,,,percent of total billed charges,,,881.28,,,percent of total billed charges,,,872.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,853.74,,,percent of total billed charges,,,872.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT NECK ST WO CNT,3522752,CDM,351,RC,70490,CPT,,,,,,outpatient,facility,,,918,385.56,109.95,881.28,,780.3,,,percent of total billed charges,,,247.86,,,percent of total billed charges,,,631.58,,,percent of total billed charges,,,617.81,,,percent of total billed charges,,,775.71,,,percent of total billed charges,,,,,,,,,798.66,,,percent of total billed charges,,,798.66,,,percent of total billed charges,,,780.3,,,percent of total billed charges,,,881.28,,,percent of total billed charges,,,872.1,,,percent of total billed charges,,,,,,,,,826.2,,,percent of total billed charges,,,,,,,,,853.74,,,percent of total billed charges,,,872.1,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,716.96,,,percent of total billed charges,,,835.38,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT NECK ST WO CNT,3522752,CDM,351,RC,70490,CPT,5522,APC,,,,outpatient,facility,,,918,918,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT NECK ST W ANDWO CNT,3522760,CDM,351,RC,70492,CPT,,,,,,inpatient,facility,,,1371,575.82,1165.35,1316.16,,1165.35,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1192.77,,,percent of total billed charges,,,,,,,,,1233.9,,,percent of total billed charges,,,1316.16,,,percent of total billed charges,,,1302.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1275.03,,,percent of total billed charges,,,1302.45,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT NECK ST W ANDWO CNT,3522760,CDM,351,RC,70492,CPT,,,,,,outpatient,facility,,,1371,575.82,183.74,1316.16,,1165.35,,,percent of total billed charges,,,370.17,,,percent of total billed charges,,,943.25,,,percent of total billed charges,,,922.68,,,percent of total billed charges,,,1158.49,,,percent of total billed charges,,,,,,,,,1192.77,,,percent of total billed charges,,,1192.77,,,percent of total billed charges,,,1165.35,,,percent of total billed charges,,,1316.16,,,percent of total billed charges,,,1302.45,,,percent of total billed charges,,,,,,,,,1233.9,,,percent of total billed charges,,,,,,,,,1275.03,,,percent of total billed charges,,,1302.45,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1070.75,,,percent of total billed charges,,,1247.61,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT NECK ST W ANDWO CNT,3522760,CDM,351,RC,70492,CPT,5571,APC,,,,outpatient,facility,,,1371,1371,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT ORB PF SEL IAC W CNT,3522778,CDM,351,RC,70481,CPT,,,,,,inpatient,facility,,,1090,457.8,926.5,1046.4,,926.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,948.3,,,percent of total billed charges,,,,,,,,,981,,,percent of total billed charges,,,1046.4,,,percent of total billed charges,,,1035.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1013.7,,,percent of total billed charges,,,1035.5,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT ORB PF SEL IAC W CNT,3522778,CDM,351,RC,70481,CPT,,,,,,outpatient,facility,,,1090,457.8,183.74,1046.4,,926.5,,,percent of total billed charges,,,294.3,,,percent of total billed charges,,,749.92,,,percent of total billed charges,,,733.57,,,percent of total billed charges,,,921.05,,,percent of total billed charges,,,,,,,,,948.3,,,percent of total billed charges,,,948.3,,,percent of total billed charges,,,926.5,,,percent of total billed charges,,,1046.4,,,percent of total billed charges,,,1035.5,,,percent of total billed charges,,,,,,,,,981,,,percent of total billed charges,,,,,,,,,1013.7,,,percent of total billed charges,,,1035.5,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,851.29,,,percent of total billed charges,,,991.9,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT ORB PF SEL IAC W CNT,3522778,CDM,351,RC,70481,CPT,5571,APC,,,,outpatient,facility,,,1090,1090,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT ORB PF SEL IAC WO CNT,3522786,CDM,351,RC,70480,CPT,,,,,,inpatient,facility,,,916,384.72,778.6,879.36,,778.6,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,796.92,,,percent of total billed charges,,,,,,,,,824.4,,,percent of total billed charges,,,879.36,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,851.88,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT ORB PF SEL IAC WO CNT,3522786,CDM,351,RC,70480,CPT,,,,,,outpatient,facility,,,916,384.72,109.95,879.36,,778.6,,,percent of total billed charges,,,247.32,,,percent of total billed charges,,,630.21,,,percent of total billed charges,,,616.47,,,percent of total billed charges,,,774.02,,,percent of total billed charges,,,,,,,,,796.92,,,percent of total billed charges,,,796.92,,,percent of total billed charges,,,778.6,,,percent of total billed charges,,,879.36,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,824.4,,,percent of total billed charges,,,,,,,,,851.88,,,percent of total billed charges,,,870.2,,,percent of total billed charges,,,,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,109.95,,,fee schedule,,,,,,,,,715.4,,,percent of total billed charges,,,833.56,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT ORB PF SEL IAC WO CNT,3522786,CDM,351,RC,70480,CPT,5522,APC,,,,outpatient,facility,,,916,916,58.06,162.68,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,114.43,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,112.19,,,fee schedule,,,,,,,,,,,,,,,162.68,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",151.46,,,fee schedule,,,,,,,,,,,,,,,,,,,,,112.19,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,112.19,,,fee schedule,,,112.19,,,fee schedule,,,58.06,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CT ORB PF SEL IAC W ANDWO CNT,3522794,CDM,351,RC,70482,CPT,,,,,,inpatient,facility,,,1181,496.02,1003.85,1133.76,,1003.85,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1027.47,,,percent of total billed charges,,,,,,,,,1062.9,,,percent of total billed charges,,,1133.76,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1098.33,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CT ORB PF SEL IAC W ANDWO CNT,3522794,CDM,351,RC,70482,CPT,,,,,,outpatient,facility,,,1181,496.02,183.74,1133.76,,1003.85,,,percent of total billed charges,,,318.87,,,percent of total billed charges,,,812.53,,,percent of total billed charges,,,794.81,,,percent of total billed charges,,,997.94,,,percent of total billed charges,,,,,,,,,1027.47,,,percent of total billed charges,,,1027.47,,,percent of total billed charges,,,1003.85,,,percent of total billed charges,,,1133.76,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,1062.9,,,percent of total billed charges,,,,,,,,,1098.33,,,percent of total billed charges,,,1121.95,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,922.36,,,percent of total billed charges,,,1074.71,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CT ORB PF SEL IAC W ANDWO CNT,3522794,CDM,351,RC,70482,CPT,5571,APC,,,,outpatient,facility,,,1181,1181,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CTA HEAD W CNT ANDPP,3522810,CDM,351,RC,70496,CPT,,,,,,inpatient,facility,,,1306,548.52,1110.1,1253.76,,1110.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1136.22,,,percent of total billed charges,,,,,,,,,1175.4,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CTA HEAD W CNT ANDPP,3522810,CDM,351,RC,70496,CPT,,,,,,outpatient,facility,,,1306,548.52,183.74,1253.76,,1110.1,,,percent of total billed charges,,,352.62,,,percent of total billed charges,,,898.53,,,percent of total billed charges,,,878.94,,,percent of total billed charges,,,1103.57,,,percent of total billed charges,,,,,,,,,1136.22,,,percent of total billed charges,,,1136.22,,,percent of total billed charges,,,1110.1,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,1175.4,,,percent of total billed charges,,,,,,,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1019.99,,,percent of total billed charges,,,1188.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CTA HEAD W CNT ANDPP,3522810,CDM,351,RC,70496,CPT,5571,APC,,,,outpatient,facility,,,1306,1306,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 145.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Price claim to $0.00 if it contains IP-only procedures.     Apply Method II CRNA pricing     Pay this percent instead of a zero amount: 60.00%     Percent when code not payable by Medicare: 60.00%     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",253.11,,,fee schedule,,,,,,,,,,,,,,,,,,,,,187.49,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",other,,"Interim Value: Not Covered By Medicare   MEDICAL/SURGICAL Procedures:       Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):     [MEDICARE OPPS COVERED CODES]: ($0.00)     [ANY CODE]: (100% of submitted charges)       No Mod 50     Apply the following multipliers to the calculated amount from above for      1st procedure and all subsequent procedures payable at 100%.       If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.       Reimbursement shall not exceed 100% of submitted charges. Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (100% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Pay this percent instead of a z",,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,97.96,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Procedure Lookup Tables:    [ANY CODE]: $0.00     1st procedure and all subsequent procedures payable at 100% of above rate.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [WY MEDICAID MFS 55 POC PROCS]: (55.00% of submitted charges)    [WY MEDICAID MFS 70 POC PROCS]: (70.00% of submitted charges)    [WY MEDICAID MFS 80 POC PROCS]: (80.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 100% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Alternate APC table: [WY MEDICAID ACUTE APC]     Alternate HCPCS Fee table: [WY MEDICAID MASTER FS]     "
CTA NECK W CNT ANDPP,3522836,CDM,351,RC,70498,CPT,,,,,,inpatient,facility,,,1306,548.52,1110.1,1253.76,,1110.1,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,1136.22,,,percent of total billed charges,,,,,,,,,1175.4,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,service not payable,,,,,,,,,,,,,,,,,,,,,,,,
CTA NECK W CNT ANDPP,3522836,CDM,351,RC,70498,CPT,,,,,,outpatient,facility,,,1306,548.52,183.74,1253.76,,1110.1,,,percent of total billed charges,,,352.62,,,percent of total billed charges,,,898.53,,,percent of total billed charges,,,878.94,,,percent of total billed charges,,,1103.57,,,percent of total billed charges,,,,,,,,,1136.22,,,percent of total billed charges,,,1136.22,,,percent of total billed charges,,,1110.1,,,percent of total billed charges,,,1253.76,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,1175.4,,,percent of total billed charges,,,,,,,,,1214.58,,,percent of total billed charges,,,1240.7,,,percent of total billed charges,,,,,,,,,,,,,,,187.49,,,fee schedule,,,187.49,,,fee schedule,,,183.74,,,fee schedule,,,,,,,,,1019.99,,,percent of total billed charges,,,1188.46,,,percent of total billed charges,,,,,,,,,,,,,,,,,,,,
CTA NECK W CNT ANDPP,3522836,CDM,351,RC,70498,CPT,5571,APC,,,,outpatient,facility,,,1306,1306,97.96,271.86,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,191.24,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",other,,"Group (Sum Of):   Is:  Procedure Lookup Tables:    [HUMANA MA A0425 PROC]     1st procedure and all subsequent procedures payable at 100% of base price in table per unit.   Procedures are sorted by table amount prior to applying multipliers.   Plus:  Medicare OP Reimbursement:     Ambulatory Payment Classification (APC) pricing    Override total payment with 102.00% of Medicare total payment     Use this provider number in place of provider number from claim: 530012     Replace blank service dates with Service To date     Zero denied totals     Add Mod 25 to force payment     Ignore CCI edit 039     Ignore CCI edit 040     Ignore OCE edit 40 to force payment     Ignore Medicare From and To Date Rule     Bundle Mod 91 Lab     Apply Modifier CT     Apply Modifier FX     Apply Modifier FY     Apply Modifier JG     Apply Modifier CS     Apply IP-only Logic     Number of retroactive years on weight adjustment: 0     Consume Units     Consume Charges     Ignore the Device Code edit    Home Health Pricing (on or after Jan. 1, 2020)   Apply Non-timely submission reduction    Hospice Pricing ",,,,,,,187.49,,,fee schedule,,,,,,,,,,,,,,,271.86,,"Group (Sum Of):   Is:  MEDICAL/SURGICAL Procedures:     Fee Schedules (When tables contain duplicate codes, reimburse code with first code found in the fee schedules listed below):    [MEDICARE OPPS COVERED CODES]: ($0.00)    [ANY CODE]: (60.00% of submitted charges)     No Mod 50    Apply the following multipliers to the calculated amount from above for     1st procedure and all subsequent procedures payable at 100%.     If not found in fee schedule OR fee schedule amount is zero, then bypass processing of the procedure.     Reimbursement shall not exceed 100% of submitted charges.  